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The Worst Mistake Students Make with First Aid for the USMLE Step 1

 

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When people find out that I scored 270 on the USMLE Step 1, one of the most common questions I get is, “how many times did you read First Aid”?  The answer is not what you would expect (hint: I didn’t even finish it once), and having tutored dozens of medical students in USMLE, shelf, and other exams has only strengthened my convictions.  Here is one such question I received recently:

Hello,

Great post, I am taking your advice and getting through more questions via integration and application v. passive reading/”active” memorizing. How many times were you able to get through First Aid during your study preparation? I was unsure how beneficial questions would be v. numerous FA read throughs? I will be able to finish it 1-2 times MAX… maybe 1.5x. I am not sure how to most efficiently manage my time, my exam is in 3 weeks. Thanks!

Forever Estudying

Dear Forever,

Thank you so much for your fantastic feedback, and for your contribution to the blog.  Your question is one all of us have asked ourselves.

How many times should you read through First Aid for the USMLE Step 1?

I never read through First Aid for the USMLE Step 1.  Not even one time.  I don’t think I even covered every section in First Aid by studying the relevant sections after doing QBank questions.  Did I just feel so insanely confident that my brilliance would carry me through (haha, right), as it has for every other test in my life (heck no; I’m not very “smart” in the traditional sense, and that certainly has never helped me on an exam).

I can count only a single USMLE Step 1 question from my actual test that I got right because of a random “buzzword” I had learned from First Aid

I can still remember the time that I decided, several days before Step 1, that it would be a good idea to skim First Aid, to see what I knew.  I expected, probably naively, that I would know most if not all of the words in the book, that my study method which had raised my NBMEs to 260+ would help me to recognize most of the relevant material.

I was wrong.  I read through a cardiology paragraph in First Aid, and a moment of uneasiness set in.  I read through the next section.  While I knew a fair amount, there was still a fair number of words/sentences that I didn’t know.

Do you think that I calmly sat there, and told myself, “no, it’s ok, you’ll be fine, all those people who said all you have to do is read First Aid over and over again and memorize all of its details were just wrong”?

Heck no.  I began to panic.  Thoughts flooded through my mind like, “AAAAAAHH, WHAT HAVE I BEEN DOING THIS ENTIRE TIME??  I’M DOOMED.”  I began to calculate how many pages I would have to read per hour before my exam to get through all of First Aid.

But then something strange happened.  I took a deep breath, took a step back, and told myself to chill.  I did a mental inventory of my most recent USMLE World blocks, and tabulated the number of questions I got right because of strict knowledge vs. my ability to apply/integrate the knowledge that I had.  The more I thought about it, the more I remembered that my ability to answer UWorld and NBME questions, particularly the most difficult questions, was directly due to my ability to integrate/apply knowledge, and had much less to do with the myriad facts I had memorized from First Aid.

That’s not to say that there aren’t facts from First Aid that were the sole reason that I got certain QBank/NBME questions correct.  But after my test (on which I scored 270), I can count only a single USMLE Step 1 question from my actual test that I got right because of a random “buzzword” I had learned from First Aid (Histiocytosis X and birbeck granules).

Why, then, do we all struggle with the question of how many times to read through First Aid?

The answer depends on your beliefs of the ingredients of Step 1 success

When I was deciding how to study for Step 1, I heard lots of conflicting advice.  On one side, I heard all of the people who told me all I had to do was read and re-read First Aid, and memorize every single detail in it; the focus was more on rote learning over true understanding of the material.  Most people, in fact, seemed to focus on rote learning over true understanding of the material.

The biggest mistake students make: focusing too much on the number of pages covered rather than the amount of information they can apply and integrate.

However, there was a small minority of students that I spoke with who not only seemed happy with their scores, but who told me that they had regretted all of the time they’d spent simply trying to cram FA details into their head.  One particularly insightful individual laid it out to me this way: 50% of the test is knowledge, and 50% of the test is knowing how to use that knowledge.  Both are necessary, and neither alone is sufficient.

Now ask yourself, if Step 1 is really 50% knowledge, and 50% application/integration, how many times should you read First Aid?  To me, that is the wrong question, and is the biggest mistake students make – focusing too much on the number of pages covered rather than the amount of information they can apply and integrate.  Instead, no matter how much time I had left before my test, I would focus on what I could be doing to master the fundamentals to the best of my ability.

But what about all of the material I would be “missing”?

Could I master all of the material for Step 1 in 3 weeks?  Not a chance.  As a tutor, one of the most common mistakes I see is that students feel so time-pressured that they feel that they don’t have the TIME to go through things in depth.  Instead, they feel the need to rush through it in whatever time-frame they have, just so they’ve “gone over it once.”  It helps them sleep better at night (temporarily) if they can tell themselves they’ve “covered” the First Aid sections in cardio/pulm/GI in 6 days, rather than cover two systems (or even just one) over that time.

That is, until they see that their NBME scores aren’t improving.

Let me tell you a story of two students I worked with recently.  One student, we’ll call “The Hare”: she felt so much anxiety that she had “so much material to cover” that she never felt she had the time to devote to learning things in depth.  Virtually every time we met, I would remind her that she needed to learn things at greater depth, but the answer was always the same, “I just don’t have the time.”

Another student, “The Tortoise,” took a different approach, instead focusing several days or more on each organ block, taking as much time as necessary before he felt like he really understood the organ before he moved on.  With Tortoise, if anything, once or twice I had to remind him to not spend TOO much time on any particular block.

What were the results?

To read about what happened to these students, as well as my suggestions for what to do next, please support the site below!

The Hare covered MUCH more of First Aid.  The Tortoise?  Many fewer pages.

Tortoise: 128 to 175 in 1.5 months (he raised his score to 201 over the ensuing month).  Hare: 162 to 168 over the same time period.

Now, Tortoise still has several organ blocks left to cover, but we are confident that he will continue to raise his score as he learns each new block in-depth.  Hare, however, had to spend the following weeks/months going back and re-learning all of the things she could have been learning over the preceding 1.5 months.  Said a different way, Tortoise only has a handful of subjects left to cover, while Hare had to slowly make her way through the entirety of the material, again.

It is MUCH better to spend the time to learn things so you never have to go back.

Obviously, you can’t draw too many conclusions from two stories.  Generally, however, I’ve found this to be true: the students who take the time to learn things in depth are the same students who make the most progress on their NBME/UWSAs.

What should you do instead?

1. Honestly assess what has helped you get NBME/UWorld/Kaplan questions right

If you’re anything like me or students I’ve tutored, you’ve probably found that rote learning makes up a very small number of questions on NBME exams (particularly the ones after NBME 7).  If you believe that the exam will be 50% knowledge, and 50% your ability to integrate/apply that knowledge, the question of how many times to read First Aid becomes much less important than how to best master the material.

2. Master the fundamentals

Integrating and applying knowledge is much easier said than done.  (Re)-read my strategy for how to make sure to master the QBank and First Aid material in the most efficient way possible to crush Step 1.

3. Craft a plan for the final 1-2 weeks

The last 1-2 weeks are a different beast than the preceding weeks.  (Re)-read my suggestions for how to be at your peak during the final sprint.

4. Map out your test day strategy

If you haven’t thought through your exact strategy for how to utilize all 8 hours of your exam for peak efficiency, read my test day strategy here (See “#5 Map Out Your Test Day Break/Lunch Time Strategy“).

5. Focus on learning depth over shallow breadth

If it were me, I’d rather learn 3 topics well, than to have read through 30 sections of First Aid.  I realize this suggestion may cause you a great deal of anxiety, but especially the way that the NBMEs/Step 1 have been evolving, knowledge is of minimal utility unless it can be applied.  This will continue to be true clinically, as the best clinicians I’ve ever had the privilege of working with at Stanford, MGH, and elsewhere have a deep understanding of the human body and the techniques we use in medicine.

What do you think?  Was I silly for not having finished First Aid?  What tricks have you found to get through the Step 1 “Bible”?  Let us know in your comments!

  • Kevin Mathew

    Hey! I can’t tell you the joy i am having for finding this website. this is seriously what i needed. I would really like your advice on couple of things. I am sitting for Step 1 end of january. Started doing firstaid and to get the deeper understanding i am using Kaplan videos along with step 1 lecture notes. What i want to know is what you did to get the deeper understanding? anatomy for instance is freaking me out. Its been a while since i have done that. Pathoma is amazing i need to send Dr Satter a Thankyou card, but i feel like its not enough. Goljin maybe?
    Questions:
    1. Right resources to get deeper understanding of content. Especially Physiology.
    2. Would you recommend using kaplan Qbank and usmle rx at this earlier stage? (i have read ur post on usmle world, i am keeping it for the end once i have a full picture of the course content)
    3. I started using Anki but it really takes a lot of time. Should i use other student shared cards? are they useful?
    4. For someone starting from scratch. Step 1 in 5 months. What should be the ideal plan.

    I know a lot of queries. I really appreciate your help. Best of luck for future.

    • Yousmle

      Hi Kevin,

      Thank you so much for your kind words and positive feedback!  It means a lot to hear =).  To address your questions.

      1) Honestly, resources are important, but I would argue that equally important is actually working to understand rather than just memorizing.  There will be things you have to just memorize, but generally, the more you understand, the better you will do.  Since you asked, I used Goljan for path, and Costanzo for phys, and was happy with both of them.  For other recommendations, I keep them on the “Resources” page (you can see the tab at the top of any page on the website).
      2) I used Kaplan early, and probably had finished 25% by the time I did my actual studies.  I think it can certainly be useful, particularly to see what kind of things you will be expected to know, and how they word the question, but I was not one of those people who had finished 2 QBanks by the time they started their focused studying for Step 1.  My goal was to get as much depth of understanding as I could.
      3) I’m not a huge fan of shared decks, since I found a lot of utility in making my own cards, plus I was never certain where other people were getting their facts, etc.  I share some of my own cards to give you an idea of the kinds of cards I made, and how I made them, so you can (I hope) spend less time with the learning curve than I did!
      4) Hard to answer, but generally, I would focus on understanding over trying to attain any magic number of questions/qbanks/etc.  My general goal at that point was to understand as many things in First Aid as possible, not to have just memorized them, since I wasn’t likely to get another shot at learning any of those topics in as great of depth again.

  • Kevin Mathew

    hey Alec! i keep up with ur latest articles, really enlightening. I have started using Anki on ur advice and have found it really useful. Lately I hit a wall.
    1. I have gone through all resources for Biostats (i.e. BRS, followed by Questions) It takes almost 3-4 min to make sense and get it done. Any idea how i can practice more with regard to biostat & epidemiology?

    2. ANATOMY. Thats really troubling, esp Gross and embryology. Recent Exit survey from those who have taken exam say Anatomy is weird and they saw 3-4 Qs in every block. I don’t think i can afford to leave it to luck. Any idea hows to prepare for it? also any starter resource to make sense of CT scan and MRI. ? I really like Wayne University website. Its really good. What would u suggest?

    • Yousmle

      Hi Kevin!

      Thank you so much for your message. For bio stats, a lot of it is just practice. Make sure that you create cards that force you to go to the bio stats equations and thought processes. Anatomy is a bit more difficult, but typically I found the question banks to be sufficient. You can take screenshots of pictures, including MRI and CT, with arrows that will test you on the anatomy.

      Best of luck!

      Alec

  • TI

    HI alec,
    Here is the question I asked before:
    I am writing to ask you about how to efficiently use UWorld and learn
    what they have to teach us through the questions. For example, I try to
    read the answer explanations and write down notes but it takes me hours
    to get through one set of questions. And by the next few days I already
    forget what I read. I try to correlate the explanations with FA but
    that takes a lot of time too. And with school going on it just doesn’t
    seem like it’s very efficient method. Any advice would be appreciated.

    • Yousmle

      Hi TI,

      Great question! The best advice is to make sure that you write down the most important points, like from the educational objective, from the questions that you are missing. Make sure to make Anki cards from these, and review them. Otherwise, you are very likely to forget the information.

      Best of luck!

      Alec

  • Mintyy f

    So I’ve spent the last couple weeks hyperventilating. Just wanted to say thanks for all these blogs, I couldn’t agree more with what you said in regards to many things. I’m awful at memorization and always can only do things on a conceptual level. So when reading advice from students saying just FA is enough with UW, I agree but not entirely. While its great for the hy stuff, it doesn’t integrate anything and I find myself going back to primary sources to find out how certain things connect with one another. A got a lot of *crap for that, saying it was a waste of time and if I just memorized FA I’d be good. But as I said, I’m a god-awful at memorization. Better at the ‘the thing-a-mabob- stimulates the other thing-a-majiggy, but thats bad so this drug blocks that badass!’. For the most part i hyperventilate thinking I’m never going to get through the FA at this rate.. Even if I do fully understand everything I’ve covered to this point, it didn’t seem like enough. But I think reading through this article in particular made me breath a bit. And feeling super comfortable with the questions you asked in the tutoring stuff. I do have one thing I’m concerned about though, histology. Just thinking about it makes me nauseous. I just can’t seem to get any sort of grip on it. I have no idea how in the world I passed that class, and everything looks the same. And than I think if I can’t even see the normal, how in the world am I suppose to see the abnormal and path. And I look at the goljan pictures while I’m reading a chapter and I freak out all over again. All the words make sense but the pictures just.. ah. Any advice would be greatly appreciated.

    • Yousmle

      Thank you so much for your kind words. I can definitely relate to feeling the need to understand things, and having other people not understand why I wasn’t just memorizing First Aid again and again.

      As far as histology, I would recommend making Anki cards of the things that you don’t know, so you can get used to recognizing the normal. Then make cards on pathology slides, asking yourself to identify things, and even asking for things like pathogenesis or related topics, to push your understanding further.

      Best of luck!

      Alec

      • Mintyy f

        You are awesome, thanks for the advice. I don’t really consider myself patient or tamed enough to actually go through and make all the flashcards. But I was wondering, do yours include that? They seem like a worthwhile investment and I’ve already considered purchasing them. Although even if they didn’t, I think it would be a good guideline to making my own and just adding to the deck you are selling? (I’m assuming thats possible on the anki program?)

        And again thank you so much for having this blog up. Your pretty much a god for all the help and advice you give!

        • Yousmle

          Thanks much for your kind words. Because of copyright issues, there are no histology cards currently, although there are cards that certainly have descriptions, with explanations of histologic features. You are correct in that they have been a fantastic guideline for making your own cards, which you can add to, which is certainly easier than making an entire deck from scratch.

          Let me know if there’s anything else I can help with!

          Alec

  • Catherine De Aragon

    Hi Alec, I would like to get your opinion on Qbanks. I just started M2, and would really like to start using a Qbank to help me remember and use the concepts and facts from class, and maybe to review some M1 material. I would really like to use Uworld, as I am not sure I would be able to go through all of it during dedicated study period. But I know most people would recommend using it only for that period, and use Kaplan or some other Qbank instead. I would really like your opinion. Thank you so much.

    • Yousmle

      Hi Catherine,

      Personally, I prefer Kaplan first, then UW second. I’d save UW as a means of testing yourself and ability to understand the material. If you use spaced repetition effectively, you shouldn’t really have to go over a QBank more than once.

      Alec

  • Thilini Sandamali Pathigoda

    You are correct , i am currently experiencing that! I and my boy friend study together for step 1. he improves his marks in great numbers, i know now.. i have this hare method. he is tortoise! i sometimes laughed at him since he is slow! but when it comes to marks he is the best!

    • Yousmle

      Hi Thilini! Thanks so much for your message! I definitely agree that slow and steady wins this race – I hope these experiences have helped!

  • ABC DEF

    Hey Alec,

    I just completed my first pre-clinical year.

    I don’t really think I remember the material that I learnt much during the year because I was the ‘hare’ kind of guy. I also admit that I put in less than 10% of my effort into studying the material…

    I would study/cram everything in and dump it in the exam, coming out forgetting virtually all that I went into the room with (ended up with an average of B+ for the whole year).

    SO MY BASICS ARE PRETTY SHIT.

    My real question are:

    1. Should I go over everything that I have learnt this year thoroughly before starting UWorld? Why and Why not?

    2. What do I do with the questions relating to organ systems / contents that I have not covered yet? Do I ignore them to do later? Do I learn from them? Do I research more about them?

    3. When you say that the ‘ability to apply and integrate information is more important than rote learning/knowledge'(something along the line), what is the knowledge threshold you need to be able to say that? Basically, how much knowledge do you need to have before you focus on applying and integrating information rather than gaining more knowledge?

    Sorry for the stupid questions!

    Thank you so much! 😀

    • Yousmle

      Hi, thank you for your message. I’m not sure how your system is set up, but if you have another year of studying, my best advice would be to try and learn the things that you were supposed to be learning with your classes, and save going back and relearning things until later. Certainly, if you can go back and have time, you can do so, but I wouldn’t spend too much time trying to do this, since it will only make it more difficult for you to learn the stuff that you are covering with your classes.

      Remember, the most important thing is that you learn how to learn. Once you have this, the rest will be more straightforward, but it’s easiest to do this focusing on the material you have in front of you, rather than trying to go back and relearn things you have already supposedly covered.

  • Chris

    Hi! So happy to have run into your website. I’m only starting to study for my Step 1 and I figured I needed a baseline exam first just to see where I’m at and what areas I would need to focus more on (I was thinking that’s a good strategy, but please let me know if it’s not). So I was thinking of taking an NBME test for that. Can you possibly give a list perhaps as to the order of the NBME tests we to take to gauge just where we stand? Also, how often or after how many days should we decide to take another NBME test? Cuz I was thinking of just picking random tests every 2 weeks.

    Thanks! Chris

    • Yousmle

      Great question, Chris. I definitely recommend taking an NBME practice exam to start. I typically start w NBME 12, mainly because there doesn’t seem to be one test that is better than others at predicting the score, and since NBME 12 was released the longest ago, it will be least reflective of any changes to the test. I usually then have students do another NBME every 2-3 weeks, depending on their overall schedule.

      Best of luck!

      Alec

      • Chris

        Thank you for the reply, Alec! Do you recommend I start with the Standard-paced or the Self-paced one? Also, when do you recommend I do UWorld?

        • Yousmle

          Standard paced.

          • Chris

            Alec, I really need your help. I’m pretty bummed out. I just tried NBME 12 and my score was ridiculously horrid (130 to be exact). I thought I would’ve done slightly better than that because I felt I knew the answers to at least some of the questions. I haven’t scheduled my exam yet but I was hoping to do it before this year ends. I just subscribed to UWorld qbank + self-assessment, I bought First Aid, Constanzo physiology, and Pathoma. What should I do? I’ll appreciate any help.

          • Yousmle

            Yikes. Without having worked with you, it’s hard to know exactly what the issue is. However, in my experience in tutoring students who score this low initially, it’s never just as simple as “buy First Aid, Costanzo, and Pathoma.” The resources aren’t really the issue – it likely goes much deeper, to how you’ve been APPROACHING your learning. That is a much bigger topic. It will take a great deal of dedicated work to become a more effective learner, but the good news is that you’re figuring this out now, and not after you’ve been studying improperly for a year!

 

ROCK MICROBIOLOGY, even if you SUCK AT MEMORIZING!

With the FREE micro deck of more than 130+ Anki cards you will be practically BEGGING to get as many micro questions on your exam as possible.

it's free!
100% privacy guaranteed, no messin' around