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

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by Alec Palmerton, MD in Plan
First Aid USMLE Step 1 Mistakes

After scoring 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). I’ve since tutored hundreds of medical students in Shelf and USMLEs. My experiences have strengthened my conviction that most students use First Aid wrong.

Here is one such question I received recently:

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 helpful questions would be v. numerous FA read-throughs? I will be able to finish it 1-2 times MAX… maybe 1.5x. How do I most efficiently manage my time? My exam is in 3 weeks. Thanks!
Forever Studying

Read through First Aid 1-2x in 3 weeks? Yikes!

In this article, you will learn:

  • When reading First Aid works (and when it doesn’t)
  • The actual number of “passes” through First Aid you should make
  • How it feels not to read First Aid cover-to-cover
  • What you should do instead of re-reading First Aid

Worst First Aid Mistake = Believing Step 1 is a Test of Fact-Accumulation

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

However, a minority of students told me that they wished they’d crammed fewer FA details. I listened carefully because this group seemed happiest with their Step 1 scores.

High Step 1 Scores Require You to Apply Concepts

One of the highest-scorers told me this:

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.

She ended up matching into Harvard ENT, so she knew what she was talking about.

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

Tracking FA Pages Read is Easier. Easy Doesn’t Mean Right.

Now ask yourself this. If Step 1 is 50% knowledge, and 50% application/integration, does it matter how many times you read First Aid?

Asking how many “passes” of First Aid is the wrong question, and is the biggest mistake students make.

Here’s a joke that illustrates the perils of counting First Aid passes.

A policeman sees a drunk man searching for something under a streetlight and asks what the drunk has lost. He says he lost his keys and they both look under the streetlight together. After a few minutes, the policeman asks if he is sure he lost them here. The drunk replies, no, and that he lost them in the park. The policeman asks why he is searching here, and the drunk answers, “this is where the light is.”

It’s easier to count the number of pages of First Aid we’ve read. However, looking for things where the light won’t help you if you’re looking in the wrong place.

Comparatively, it is much harder to measure mastery. You may realize your Step 1 score depends on your ability to apply and integrate. However, how do you know how well you’ve learned application and integration of the material?

(To read UWorld + First Aid: 4 Keys to Mastery (#4 Bumped Me to 270 from 236), click here).

First Aid Worst Mistake

Like looking for keys where the light is best, counting the number of First Aid pages you’ve read is easier. However, it doesn’t matter if you’re looking in the wrong place.

I Never “Read Through First Aid.” This is What Happened.

I never read through First Aid for the USMLE Step 1 a single time. Not once.

Let me be clear: I used First Aid. However, I never read through the “Step 1 Bible” page by page.

Instead, my approach was to do QBank questions first, then to use First Aid as a reference later. This QBank-first approach didn’t even lead to covering every First Aid topic.

I was extremely nervous about not reading First Aid. I read the same accounts as you have. My friends would all tell me how many pages of First Aid they’d covered. I’d heard of people who had scored 250+ on Step 1 who had “just repeated First Aid.” (Although I hadn’t actually spoken to anyone who had “just read First Aid”).

However, I wanted to understand the material. Reading First Aid rarely led to a deeper understanding.

Did I Learn the First Aid Material Well?

You’re probably wondering how much of First Aid I actually knew, despite not reading it. Maybe I’d picked up everything via class, or another mechanism?

Several days before Step 1, I decided to answer that question. To see how much I knew, I thought it would be a good idea to skim First Aid.

I was naive. I expected that I would know most of – if not all – the words in the book. After all, my NBMEs were 260+ at this point. My “coverage” of First Aid topics was the reason my practice scores had improved so much, right?

I was wrong. After reading through the First Aid cardiology section, a moment of uneasiness set in. I didn’t recognize much of it. Then I went through the next section. While I knew a fair amount, there was still a fair number of words/sentences that I didn’t know.

Most concerning to someone about to take the most critical test of their medical career? There were lots of “facts” that I didn’t know.

Do you think that I calmly sat there, and told myself, “Alec, it’s ok, you’ll be fine. All those people who told you to repeat and memorize First Aid 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. (It would have been close to 100 pages/hour. Wasn’t gonna happen).

Buzzwords vs. Mastery: Which Is More Important?

But then something strange happened. I took a deep breath, took a step back, and told myself to chill.

Next, I did a mental inventory of my most recent USMLE World blocks. I tabulated how many items I got right because I knew facts vs. I knew how to apply my knowledge.

The more I thought about it, the calmer I became. Answering UWorld and NBME questions depended on my ability to integrate/apply knowledge. This was particularly true for the most challenging problems.

(To read The Secret to Scoring 250/260+ You Can Learn Right Now: Question Interpretation, click here).

Few USMLE Questions Rely on “Buzzword” Knowledge Anymore

Few, if any, correct items were from the myriad facts I had memorized from First Aid.

That’s not to say that First Aid facts won’t help you get some questions right. However, only a single item from my test required knowing a random “buzzword” from First Aid. (Histiocytosis X and Birbeck granules).

Don’t memorize words from First Aid. It is only distracting you from the key to a high USMLE score: mastery.

First Aid USMLE Step 1 Mistakes

Few if any USMLE questions can be answered using First Aid facts. Stop memorizing First Aid!

But What About the Material You’ll “Miss”?

Could I master all the material for Step 1 in 3 weeks? Not a chance. Yet that is the impossible goal most students set for themselves.

As a tutor, one of the most common mistakes I see is students’ unrealistic timelines. They have a particular goal score. However, they tell themselves they have to take their tests by an arbitrary date.

“I have to get a 240+, but I only have 6 weeks to improve by 60 points. Therefore what should take a normal student 10-14 weeks, I need to do twice as fast.”

They feel so time-pressured that they think 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.” They’re relieved by “covering” the First Aid sections in cardio/pulm/GI in 6 days. (Again, it’s easier to track pages read than it is to measure amount mastered.)

By the time they take their next NBME, however, they realize something isn’t working. Instead of slowing down, however, these students move even faster. They learn even less and cram more, and the cycle of stagnant NBMEs repeats itself.

What Happens When You Speed Through First Aid

Let me tell you a story of two students I worked with recently. One student, we’ll call “The Hare.” She was anxious and felt she had “so much material to cover” that she couldn’t focus on any one thing. Every time we met, I would remind her that she needed to learn things at greater depth. However, the answer was always the same, “I just don’t have the time.”

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

What Were the Results?

The results? 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. However, 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. In other words, Tortoise only has a handful of subjects left to cover. 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, 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

Rote learning makes up a tiny number of questions on NBME exams. Don’t believe me? Tally the number of items you miss on an NBME based off of factual knowledge.

Do you believe the test is 50% knowledge, and 50% your ability to integrate/apply that knowledge? If so, forget trying to re-read First Aid. Instead, focus on mastery of the material.

2. Mastery Takes Times. Plan Accordingly.

Integrating and applying knowledge is much easier said than done. Mastery also takes time.

It’s better to learn 3 topics well than to cram 30 sections of First Aid. This suggestion may cause you a great deal of anxiety. However, knowledge is useless unless you can use it. The USMLEs focus on the application of knowledge, not on regurgitation of facts.

Not to mention understanding the material will make you a better doctor. The best clinicians have a deep understanding of the human body. They’ve mastered the tools we use in medicine.

You may be wondering how to actually achieve that integration and application. Here are more articles to help you learn how to master the material, and know how to use it:

3. Consider Whether Your Timeline Is Realistic

Mastery takes time. Most students cram as a way to survive medical school. As such, their foundation is weak when they prepare for Step 1.

You can’t overcome 2 years of cramming in 4 weeks of accelerated prep. Rushing through the material can even make things worse.

Consider what would be a realistic timeline for improvement. You may even consider taking extra time for preparation.

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!

Photo by NeONBRAND, Sven Scheuermeier

23 Comments
  1. Kate Easton Baye says:

    Hi Alec,

    Thanks so for this!

    This is exactly where I am right now and this is exactly what I needed. Despite reading ALL the articles you have written, I couldn’t put off the urge to re-read FA one last time before my exam scheduled in 3 weeks BUT I will focus of questions and Anki while brushing up of the Yousmle course contents that I need and using the questions I do these last days to review what I need to from FA.

     

    Now, I have a question, I have been able to catch up on my Anki Yousmle Step 1 and Micro decks but I am really behind on my Pharm deck. While Pharm is “not that bad” for me, there are somethings like diazoxide and diphenoxylate” and generally the way the cards are written that I only got from the few Anki cards that I have done. I will definitely plan to keep up with the deck for Step 2 CK but … with 3 weeks left, what is your advice? I have 1382 new cards and have done 298. Do I try to get through the 1382 with little to no hope of reviewing before step 1 or stick to what I have done and keeping up with reviews of the other decks.

  2. Chris says:

    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

    1. Yousmle says:

      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

      1. Chris says:

        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?

        1. Yousmle says:

          Standard paced.

          1. Chris says:

            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.

          2. Yousmle says:

            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!

  3. ABC DEF says:

    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! 😀

    1. Yousmle says:

      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.

  4. Thilini Sandamali Pathigoda says:

    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!

    1. Yousmle says:

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

  5. Catherine De Aragon says:

    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.

    1. Yousmle says:

      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

  6. Mintyy f says:

    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.

    1. Yousmle says:

      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

      1. Mintyy f says:

        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!

        1. Yousmle says:

          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

  7. TI says:

    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.

    1. Yousmle says:

      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

  8. Kevin Mathew says:

    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?

    1. Yousmle says:

      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

  9. Kevin Mathew says:

    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.

    1. Yousmle says:

      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.

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