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How I Improved My USMLE Step 1 60 Points in 2 Months

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by Alec Palmerton, MD in Plan, Yousmlers

Every year, innumerable students approach/begin their dedicated Step 1 study period, only to realize that their preparations are woefully inadequate.  So many of them try to go through multiple “passes” of First Aid, UW, Sketchy, etc., only to figure out that they haven’t achieved mastery of anything, and have way too little time to cover too many subjects.  Here is the story of a student who went through something similar, but turned around her approach to improve her USMLE Step 1 score by 60 points in 2 short months.  Here she shares her mistakes she made prior to her dedicated study period, as well as what she did right in improving her score by so much in such a short period. – Alec

Welcome Letter: Never Too Early to Start Step 1 Studying (the RIGHT way)

On the first day of medical school, I opened up my welcome letter from an upperclassman who gave the following advice: It’s never too early to start studying for Step 1. I quickly recognized that I needed to start studying for Step 1, I just didn’t know how.  Should I read all of First Aid by the end of first year? Should I go through UW twice? Should I get through the Doctors In Training videos before my dedicated study period? These were just some the questions that crossed my mind, as I talked to other students about their strategies (I realized soon enough that the answer to all my questions was no).

My Step 1 journey was long, challenging, and exhausting. But it has a happy ending. I’ll go through in detail how I was able to improve my score by 60 points in 2 months. As a disclaimer, I definitely wouldn’t recommend trying to study for Step 1 in 2 months. I wasn’t using the right approach during my preclinical years and had to essentially play catch up in my dedicated study period. So, if I had to give a welcome letter to medical students preparing for Step 1 I would advise:

Start studying early the right way.

My Initial Approach/Mistake: Sprinting Through Content  

During my preclinical years, I would essentially memorize from lecture PowerPoints and read through the accompanying sections in First Aid and Pathoma. Starting second year, I added Sketchy Medical as a visual aid to help memorize pharmacology and microbiology topics. I also bought the Doctors In Training course and finished all the lecture videos by the end of second year. The weekend before I had a block exam, I would do the respective UWorld questions. So if I had an upcoming endocrine exam, I would do about 40 UW endocrine questions the weekend before – I finished about 25% of the qBank by the time I got to my dedicated study period. My theory was that if I got through all the material from First Aid, Pathoma, Sketchy, and DIT during preclinical years, I could easily review the material a second-time during dedicated study period and be able to recall everything for Step 1. Needless to say, that theory came crashing down fast.

One week before my dedicated study period, I took my first NBME exam. I clicked on the results and saw a 168! I was in total panic mode. How could this have happened? I always scored average or above average on block exams in school. On top of that, I felt like I had already gone through all these different Step 1 resources. My confidence was totally shaken up and that’s when I started looking for help.

Understanding & Reinforcing

When I had my first individual session with Alec, I realized right away that I didn’t have a solid pathogenesis to presentation foundational understanding. Even though I did well in school, I was not equipped with the knowledge or skills necessary to do well on Step 1. For example, I knew that in states of severe starvation, red blood cells could only use glucose (rather than ketone bodies) as a source of ATP, but I never thought about why that was.* My other big mistake was that I didn’t reinforce the material I was learning. This is where Anki comes in. I had tried Anki the first few weeks of medical school but I found it cumbersome and difficult to keep up with. After going through the Yousmle tips for making Anki cards, I realized that I wasn’t making them correctly.

I used to basically type information from lecture PowerPoints as Anki cards. Incorrect example of what I used to do:

Front of Card

Paget’s Disease

Back of Card

  • Increase in osteblastic and osteoclastic activity
  • Can cause shunt
  • Can present with hearing loss
  • Risk of progression to osteosarcoma

I would copy and paste information, without having an understanding of what I had typed. I also put way too much information on the card so it would take forever to get through the whole deck. Without asking specific questions, I wasn’t given any context about the topic the card was on. So, a better way to create the cards was if I had made something like this:

Front of Card

Paget’s Disease – pathogenesis? How can it lead to hearing loss?

Back of Card

Increased osteoblastic and osteoclastic activity that causes abnormal “woven bone” architecture

Auditory foramen narrowing as a result of abnormal bone architecture

The first thing I did in the mornings during dedicated study period was review my Anki cards. It would usually take about 2 hours to get through all of them — I did a mix of my own deck as well as Alec’s Pharmacology and Step 1 decks. The Yousmle decks were helpful because they consolidated a lot of high yield topics – by going through these topics with the cards, I was not only able to gain mastery of the topics, but also set myself up to reinforce the information. Often times, I would use these decks as a starting point to figure out what to focus on and which topics I needed to study more in depth. I also felt that some of the decks were so comprehensive that I didn’t need to look to outside resources for more information (I did this for the Immuno Pharmacology, Behavioral and BioStats decks). In the beginning I made between 25-30 new cards a day but by the end I weaned down to about 10 new cards a day. I would do about 50 to 100 Yousmle cards a day – by the end I got through 100% of the Step 1 deck and about 75% of the Pharmacology deck. My approach to Anki was to make the cards simple and to be diligent about reviewing them everyday.

*(Answer: Ketone bodies can break down to acetyl-CoA, which then goes through the citric acid cycle to produce FADH2 and NADH, which act as electron carriers in oxidative phosphorylation to eventually produce ATP. Red blood cells don’t have mitochondria, where the citric acid cycle and oxidative phosphorylation take place. Therefore, the only way that RBCs can produce is ATP is by breaking down glucose via glycolysis, which takes place in the cytoplasm).

Use Yousmle Online Course Videos to Master Content Quickly and Effectively

When I got back my first NBME I knew that I needed to make drastic changes in my study strategies. The major disadvantage was that I had very little time. I had even reached out to my school asking if an extension could be possible, and while it was, it also meant delaying graduation by a couple of months, which I really didn’t want to do.  So, I decided that I was going to try to do the best that I could in the limited amount of time that I had. That meant giving 100% focus and commitment to Step 1 studying. I temporarily blocked social media and put a hold on research projects and extracurriculars. I studied between 12-14 hours a day, waking up around 5:30 am and sleeping around 11:00 pm, with an hour or two break in between to eat and workout.

Having only 2 months, I had to be very selective on the topics I chose to study. I would go through the Yousmle Online Course Videos on high-yield topics and making Anki cards on them. These videos really helped build a pathogenesis-to-presentation understanding on concepts that are often confusing like PV loops, types of hypercholesterolemias, and diuretics, just to name a few [see an example video here]. What I enjoyed most about these videos (and group tutoring sessions in general) is that we, as students, had the opportunity to teach each other. While Alec would lead most of the discussions, he would often ask students to give explanations. While this format of learning may feel intimidating initially, I found that by being able to explain to others I learned a lot more than if I were to just study in isolation. The Q&A format of group sessions forced me to think on my feet and in the long run, prepared me well for third year on the wards. Simultaneously, I would read up on my weaker topics (I started with biochem and cardio). If I didn’t understand a topic within 15 minutes of reading about it, I would write my questions and ask Alec during our individual sessions, which I found immensely helpful (and it saved me a ton of time!).

I would usually choose between 2-3 topics each day, read up on them, and make Anki cards. I only had one-shot to really master these topics because I didn’t have time to re-learn material I had already covered.  Sometimes, I would even talk out loud and pretend to teach on a particular topic, just to make sure I really understood and could articulate what I had just read. It was definitely weird talking to myself, but it worked!

Completing a Story

Ironically enough, the single-handedly most important factor that improved my Step 1 score had nothing to do with content – it had everything to do it with question interpretation. Grateful Student writes about the step-by-step process of question interpretation. I had a similar experience in which I would go through the method inconsistently and I got to a point where my NBME scores were stagnant. I improved by about 30 points the second NBME exam I took. But by the third and forth and exams, I was still floating around borderline passing. Simply mastering and reading up on topics wasn’t enough. I had to understand what the questions were asking and how to approach them. Alec gave honest feedback and said my scores won’t improve unless I go through the method for each question and write out my interpretation line-by-line. So I did. I would go through 40-60 UW questions a day. In the beginning it would take me about 3 hours to go through this method for each question. It required a lot patience and mental energy, but eventually I got into this instinctive rhythm, in which after every sentence I would try to complete the next part of the story.

Example Question: “A 34-year-old woman comes to the clinic with weight loss and tachycardia.”

My Thoughts: Okay, so maybe wl & tachy are from hyperthyroidism or some kind of malignancy.

Question: “On physical exam, her PCP notices lid lag and proptosis.”

My Thoughts: Hyperthyroidism from Grave’s Disease. Pathogenesis of Grave’s = Autoantibody that stimulates TSH receptor  Proptosis b/c fibroblasts behind orbit express TSH receptor. In Grave’s TSH activation can result in glycosaminoglycan buildup → inflammation → fibrosis + edema → proptosis

For Step 1, every sentence has a purpose. It took me awhile to figure out that question interpretation is really about trying to tell a story – making sense of the different pieces of information to create a cohesive narrative. So if the question were to ask

 “What is the most effective treatment for this patient’s diagnosis?”

  1. Propanolol
  2. Methimazole
  3. Methimazole + Propanolol
  4. Lisinopril

I can ask answer with confidence that it’s C because by the time I got to the question I already knew the patient had hyperthyroidism from Grave’s disease. I would then just have to figure out what the best treatment plan would be (propranolol would slow her heart rate to control the tachycardia and methimazole blocks thyroid peroxidase to directly treat her hyperthyroidism).

Question interpretation is challenging and takes a lot of practice. I started with UW questions and then progressed to the NBME questions. I would also participate in the Online Course Group Question Interpretation Sessions 6-10 times per month, to really help solidify these skills. It wasn’t until my 5th week of dedicated study period that I really started becoming comfortable with question interpretation. But once I got it, I immediately saw a steady improvement- every week my NBME scores would increase by at least 10 points! Once the actual Step 1 exam came around, I ended up improving by a total of 60 points.

Closing Letter

Going through this Step 1 process in such a short amount of time was one of the most challenging and rewarding things I’ve ever done. There were some days that were mentally and physically exhausting, no doubt. But the time, energy and money were worth it. I learned more in those past two months than I ever did in my preclinical years. Now that I’m on the wards, I can directly see how these test-taking skills apply to practicing medicine. Memorizing and regurgitating facts aren’t going to help when it comes to patient care. Clinical reasoning is all about asking questions, making sense of symptoms, and bringing together pieces of information to develop a patient’s story.

Wishing you all the best in your future medical endeavors!


Step 1 Graduate

1 Comment
  1. Jamaal Tarpeh says:

    Hi Alec,

    I know this was asked earlier, but do you still offer your Step 1 and Step 2 combo deal if I were to order now?

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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.