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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

Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.