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How to Memorize for the USMLE Step 1 and Step 2 CK

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by Alec Palmerton, MD in Plan

We’ve all seen the buzzwords and details. Our classmates tell us that all we have to do is memorize First Aid, and we will be fine. But then, we see the dizzying array of facts to cram, and our heads begin to swim. “Rust-colored sputum.” “Crumped tissue paper appearance.” “Coffee ground emesis.” “Cherry red spot on the macula.” “Cotton wool spots.” “Cape-like distribution.”

Even worse, no matter how much we jam into our brains, we struggle with UWorld and NBME questions. Nothing feels worse than putting in work without seeing results – especially when we aren’t sure what we could be doing better.

There is no doubt that there is a ton to learn for the USMLE Step 1 and Step 2 CK. How can you possibly remember it all? How do you know or – gulp – memorize it all? And is there a better way than cramming detail after detail into our heads?

In this article, you will learn:

  • How much memorization is needed on Step 1 and Step 2 CK,
  • The ways the USMLEs have evolved over time,
  • Overlooked – but critical – rules the NBME follows when writing USMLE questions,
  • The problem ANY study technique should solve,
  • A single concept that can explain thousands of facts, and
  • Much more

Memorize SOME Things, Not Everything

As discussed before, there are indeed many things you’ll have to memorize for Step 1 and Step 2 CK. Why? Because you won’t be able to find an explanation for everything. There may not be an explanation for certain things that are known (yet).

Can I make sense of why macrophages may look like crumped tissue paper in Gaucher’s? No. Or why the particular defects in VACTERL are what they are? Unfortunately not.

Even more challenging are things for which there are explanations that I wouldn’t have been able to predict. It may make sense that statins cause myositis. However, nothing about the mechanism would have led me to expect it in the first place.

In other words, there are so many things in medicine that we can’t explain – or where the explanations aren’t intuitive. It is tempting to believe that ALL of medicine is a list of things to memorize and then look for the most efficient way. We look for pre-made Anki decks like Zanki or Brosencephalon – things that promise to be “comprehensive” with all of the facts that we “need to know.”

However, while acknowledging that there are a large number of things that “you just need to know,” I would argue that:

  • Knowing the explanation will always help you to remember/apply it better, and
  • Memorization – while a necessary evil – should be a last resort rather than the default

The USMLEs Used to Require More Memorization (Particularly Step 1)

A common argument by memorizers is that “Step 1 just tests random facts.” While it is true that there are SOME “random facts” that are tested, there are fewer and fewer questions that hinge on such knowledge.

For example, go through any NBME practice exam for Step 1 or Step 2 CK. For the questions you miss – or questions in general – go through and figure out how many were due to a lack of a particular fact. If you’re like most people, you may find that the reasons you miss questions are more often due to:

  • Unforced errors – reading too quickly and/or carelessly, so you fail to recognize a particular clue
    • Ex: reading too quickly and not seeing that question asks, “which of the following would INCREASE due to the patient’s condition?”
  • Lack of recognition – not preparing correctly, so you don’t know the significance of critical signs/symptoms
    • Ex: failing to recognize an aortic aneurysm signs/symptoms due to not having previously made sense of how it could compress the recurrent laryngeal nerve (causing hoarseness/voice changes) and/or airway structures (causing cough, dyspnea, etc.)
  • Lack of concept mastery – having memorized rather than understood a particular concept or condition
    • Ex: missing a question on sepsis because you lack an intuitive understanding of preload, afterload, and contractility

A small number of questions that remain will be due to not knowing a particular fact. However, if you’re objective, that number is small. And if you’re objective, you will also recognize that the small number of things you need to memorize shouldn’t justify trying to remember most/all of the things you’re learning by rote.

A Fundamental Problem with Memorization: Transfer

How often have you studied something only to get it wrong on a question? If you’re like many people, it happens more often than you think. There is a term for this: “transfer.”

Transfer is one of the biggest challenges to educators everywhere. It refers to learning something in one context and applying it in another. And it is a primary reason why medical students may be able to recall the most minute details of subjects they learn…and still get questions wrong on their exams.

For example, many medical students have memorized the picture-based mnemonics in Sketchy Micro or Picmonic. These memorable pictures can help with remembering many mundane details. It feels even better when you look at the pictures and remember a host of facts related to each pathogen. Your recall is high in the context you’ve learned it – the picture mnemonic – and it feels very reassuring.

However, how often does that high recall translate into questions right on your exam? Probably not as many times as you’d like. I’ve spoken with countless students who say, “oh, I love ______” resource for microbiology. However, when we look at their NBME practice exams, their microbiology scores often don’t match their confidence level.

Why? Because when we memorize something, we feel confident in that particular context. However, as soon as we try to transfer that knowledge to a novel situation – like a USMLE question – we fall short.

Transfer is always a challenge. Memorization, however, only makes it harder and leads to much more frustration to USMLE-takers.

Understanding >> Memorization, Especially For Higher Scores

If memorization isn’t the solution to transfer, then what is? Readers of this blog won’t be surprised by the answer: mastery and application of fundamental concepts.

The better you learn something, the better the chances of applying it in a novel context. Think of anything you’ve mastered. You probably can see tons of real-world examples of the related concepts. Your depth and mastery of that topic allow you to transfer that knowledge to a wide variety of different facets of life.

I had a conversation with a former hedge fund manager friend. In describing the idea of growing your knowledge foundation over time, he referenced the concept of compound interest. It’s an analogy I would never have thought of – that knowledge compounds over time. But to someone steeped in finance fundamentals, it made perfect sense. It also highlighted the power of depth of mastery and how it allows for transferring fundamental concepts to novel contexts – the exact thing you need to do on the USMLEs…and practice as a physician.

Fundamental Concepts in Medicine: An Example

But what concepts are there in medicine? Isn’t the USMLE Step 1 and Step 2 CK simply a long list of details to memorize?

A simple but powerful concept that we highlight in the Yousmle Online Course is that “likes dissolve likes.” For anyone with passing knowledge of chemistry, this concept will be familiar. If something is lipophilic (literally “fat loving”), it will dissolve in fats. Hydrophilic substances, in contrast, will be soluble in water.

If we leave it as “likes dissolves likes,” we might recognize a few things. However, most of the details related to this concept would be facts to memorize.

However, a deep understanding of this concept can explain hundreds if not thousands of facts that you would overwise have to memorize.

For example:

Lipophilicity and the idea of “likes dissolve likes” more broadly explain well why certain drugs/hormones:

  • Are given orally vs. must be given IV (fluoroquinolones have ~100% oral bioavailability, in part because of their high lipophilicity),
  • Penetrate the CSF, lungs, or other organs readily (given their high lipophilicity, it’s not surprising that fluoroquinolones ALSO have excellent CSF/lung/additional organ penetration),
  • Have high or low volumes of distribution (highly lipophilic drugs distribute widely to all tissues, causing high volumes of distribution),
  • Have intracellular vs. extracellular receptors (lipophilic steroid hormones have intracellular receptors since they can cross cell membranes),
  • Can be given transdermally (e.g., estrogen can be given as a patch, since estrogen is lipophilic)
Fundamental Concepts Can Also Allow Us to Infer/Predict Facts in Many Other Contexts

You can even INFER facts from knowing one detail by understanding a concept deeply. For example, we KNOW that caffeine crosses the blood-brain barrier to affect the CNS. It shouldn’t be surprising, then, that caffeine also has a high volume of distribution.

You’d also guess (correctly) that caffeine can be given as a patch – as can almost every other drug with CNS effects. In addition, because lipophilicity is one of the main drivers of crossing cell membranes EVERYWHERE, every drug I’ve found that has CNS effects will also cross the placenta. Why? Because if a drug can cross the cell membranes involved in the blood-brain barrier, we can also assume it will cross the cell membranes of the placenta.

So, the first step in memorizing for the USMLEs is… not to memorize. Instead, the more you focus on concept mastery and application, the fewer things you’ll need to memorize.

But how do you master and apply concepts? And what do you do with the things you can’t explain?

First, the simplest way to find a fundamental concept is always to ask, “why?” It sounds simple – and is. The most direct way to improve your learning, retention, and ability to “transfer” knowledge to novel contexts is to know WHY things happen in the first place.

See these articles to read more about how you can master – rather than memorize:

You Have to Memorize SOME Things, but NOT Everything

But what about those things you need to memorize? Again, if you’ve gotten this far, the answer should be obvious: only memorize as a last resort, NOT as your default.

The biggest mistake you can make is to assume that just because SOME things need to be memorized, EVERYTHING should be so. Instead, by asking, “why?” for everything – and memorizing only the things you can’t explain – you’ll remember more. More importantly, by mastering the essential concepts, you’ll solve the all-important transfer problem and use critical concepts on your USMLEs.

Concluding Thoughts

Memorization on the USMLE is inevitable. However, it doesn’t have to be your sole focus.

Cramming is miserable. We force-feed words into our brains, hoping to hold onto enough that we can regurgitate them on an exam. Then, we quickly forget it while making up for our sleep debt. By the time we’ve recovered, we’re already behind for our next test—the cycle repeats.

Do you feel like you’re drowning in a flood of information – barely getting by while cramming a million facts over countless hours of studying? If so, there is a better way. It will feel slower, but it ends up being substantially faster because of the compounding power of mastery.

Remember, the most effective learners take a thick textbook and make it thin. In other words, they can take a considerable number of details and distill them into a handful of core concepts. Rather than memorize the volume of distribution, means of administration, organ penetration, etc., for every drug, you can master a single idea – “likes dissolve likes.” Instead of memorizing the presentations of MI, angina, mesenteric ischemia, or compartment syndrome, focus on the core concept of ischemia = demand > supply.

If you’d like to learn more about how you can use core concepts to accelerate AND deepen your learning, we offer free consultations. You’ve dedicated your life to helping others. However, so little of the way you’ve been trained has been a help to you. We know that your unique circumstances can make your preparations challenging. Let us understand how we can best help you master – rather than memorize – for more fulfilling exams and careers.

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.