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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!

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!

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