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UWorld + First Aid: 4 Keys to Mastery (#4 Bumped Me to 270 from 236)

Guide to Mastery of Topics for the USMLEs

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by Alec Palmerton, MD in Plan
USMLE Fundamentals

Virtually everyone preparing for Step 1 will use UWorld and First Aid. But are you using them correctly, or are you wasting your time? The stakes are high. The USMLE Step 1 is the most critical exam most of us will take in our medical careers. Step 1 remains the most cited factor for giving residency interviews. Programs use it to screen applicants; they reject roughly 50% of all applications without reading them thoroughly.

So every med student wonders: how do I use UWorld and First Aid to maximize my Step 1 score? What does it take to get a 240+ or 250+?

Here, you will learn:

  1. Why most students waste time using First Aid and UWorld
  2. The origin of First Aid, and how you should use it to your advantage
  3. How I studied from UWorld and Kaplan to raise my score 34 points (from an initial NBME of 236 to my final score of 270)
  4. How to know whether you’ve mastered a topic

Table of Contents

Why Most Students Use First Aid + UWorld Wrong

Most students will use resources like First Aid and UWorld. The question is, “how?”

(To read Beyond UFAP: Why a List of Resources Isn’t a Good Step 1 Strategy, click here).

Many prefer to read First Aid first. Then, they use UWorld to “test themselves” on the material. In other words, they will learn the cardiology section in First Aid, then do cardiology questions from their QBank.

First Aid before UWorld seems logical; many students follow it. However, I don’t like the “First Aid-First” approach for two reasons:

First, without a Strong Foundation, Reading First Aid = Waste of Time

Ever heard the advice, “just read First Aid”? It’s horrible advice. Why? Because unless you know the material well first, First Aid won’t teach you. (I’ll explain why later).

If you know antiarrhythmics well already, First Aid will help refresh your memory. However, if your fundamentals are weak, First Aid isn’t the solution.

Their explanations have improved over the years. However, the essence of First Aid is the same: condensed facts you need to know for the exam. It is not conducive for having an integrated understanding of the material.

Second, passive Reading Helps Us Recognize (But Not Use) Knowledge

Have you ever read/listened to something passively, and thought, “Wow, I understand this!” Then, in a QBank question, you failed to apply it to the vignette?

This disconnect between what we can recognize, and what we can use is enormous. I may see a passage on Hashimoto’s and think, “Oh, I’ve seen that before!” But when I’m forced to differentiate between Hashimoto’s and subacute granulomatous thyroiditis I fall flat.

Waiting to do QBank questions only delays the identification of our knowledge gaps. Why? Learning new material from First Aid is challenging so we often resort to memorizing the words on the page. (Again, learning from First Aid is painful). But because we memorized the information, we get the question wrong. Too late, we realize we never really understood the material.

The result of memorizing First Aid? Having to repeat the entire process, learning the material we never understood in the first place.

The most obvious example of time-wasting? Students who read all of First Aid before they do any QBank questions. They do their “first pass,” thinking they need to see everything before they do practice problems. Only after their first practice test/QBank questions do they realize the error of their ways.

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

USMLE Fundamentals

Mastering the fundamentals from the beginning saves time and leads to a higher score.

The “First Aid-First” approach wastes time and gives us less time to improve our scores. Instead, here are the four keys to using UWorld and First Aid to maximize your Step 1 score.

1. Understand First Aid’s Purpose/Origin

So many people follow the dogma of “just do First Aid.” However, few stop and consider its purpose.

(To read The Worst Mistake Students Make with First Aid for the USMLE Step 1, click here).

Here’s First Aid’s “origin story” from an attending who had attended Yale. (First Aid’s place of birth). His recollection explains both First Aid’s simplicity and how to use it.

At the time the USMLEs came into prominence, Yale students were underperforming. Subpar Boards scores weren’t acceptable for such an elite institution. So what did they do? The authors of First Aid approached students who had taken the USMLE. Then the authors asked those students what questions were on it.

First Aid: Answers to Remembered USMLE Questions?

First Aid isn’t alone in “surveying” students about the content of their exams. (Doctors in Training comes to mind). However, what First Aid does with that information is critical. According to this attending, they write the information you would have needed to answer the question.

In other words, First Aid has the raw information needed to answer the “remembered questions” from prior test-takers.

First Aid’s origin explains the most common complaints by most Step 1 test-takers, including:

  • First Aid doesn’t have a clear order/flow between topics. (Remember, the goal is to give us an idea of what is on the test. The goal isn’t to lay it out logically).
  • Each topic feels like a jumble of mixed facts.
  • It’s hard to apply what they’ve learned from First Aid to QBank/Step 1 questions. (The First Aid approach emphasizes facts > understanding), and finally
  • First Aid does a poor job teaching something if you don’t know it already. (Again, the goal isn’t to teach. Instead, it’s telling you the topics asked/information required to answer them).
Use First Aid As a Target of What You Will Master

How does First Aid’s origin story help you study for Step 1? By giving you a target of what to master.

Unlike most med school exams, Step 1 emphasizes the application and integration of knowledge. As such, you must understand the mechanisms of disease. However, mastery of material takes time. Most students think they don’t have time to understand subjects. Instead, they search for sources of “high yield” facts that they cram.

(To read Why I Stopped Using Zanki and Brosencephalon, click here).

Don’t succumb to cramming and memorizing facts. Learn “why?” and “how?” rather than, “what?” Here are some examples:

  • Don’t just memorize that glucagon can be used for a β-blocker overdose. Instead, consider that glucagon works through Gs proteins, just as β-receptors do. Thus, β blockers and glucagon have the opposite downstream signaling. (This makes a GREAT USMLE question. It’s clinically relevant and tests application of concepts. See the Yousmle Step 1 Cards for more).
  • Calcium channel blockers extend the PR interval. Ever wonder why? Ca++ is the dominant ion used in conduction because you lack IK1 channels in nodal tissue. Because the cell can’t remove Na+ channel inactivation, Ca++ is the dominant ion in nodal tissue depolarization. (To learn more, click here).

2. UWorld = Diagnosis; First Aid = Treatment

In medicine, our treatment is only as good as our diagnosis. Prescribing antibiotics for a misdiagnosis of pneumonia won’t help if it’s lung cancer. There’s no such thing as the right treatment for the wrong diagnosis.

Studying is similar. If we misunderstand our weaknesses (misdiagnosis), our studying suffers (mistreatment).

Doing UWorld First Tells Us Where to Focus

A massive challenge for Step 1 studying is knowing how to apportion our time. We know we’re supposed to study. But which of the many weaknesses to address? And how much time to spend on each? So many students guess at their weakest subjects. They sit down with a vague idea like, “I guess I should study genetics today.”

Instead of guessing, you should use QBanks to guide your studying. Doing questions before studying content helps you diagnose your strengths and weaknesses. Making mistakes will also focus your studying. Your treatment will match the diagnosis.

My recommendation if you are studying a particular organ system/block? Do a short block of subject-specific questions, say 10-15 items. Then use First Aid and related resources to master those weaknesses.

In other words, you could do 15 cardiology questions. Doing these questions first will surface many misconceptions/gaps in your knowledge. Let’s say one of those weaknesses is “heart failure.” You’d go to First Aid’s “heart failure” section, and master the related material.

Getting Questions Wrong First Makes Your Studying More Efficient

Research suggests failing to answer a question helps with later recall. That mirrors my experiences.

Let’s say you just got a question wrong because you misinterpreted a physical exam finding. You’ll be much more engaged when learning the material later. Your purpose will be more precise.

Want an additional benefit to doing questions before learning the material? Remember that First Aid doesn’t teach well. If you get a question wrong, the First Aid explanations will make much more sense. Why? Because you will have the QBank explanation and also a clinical context to which to apply your learning.

“But Won’t My UWorld Percentages Be Lower?”

Doing QBank questions before you’ve studied the material will likely lead to lower percentages. But does that matter?

(To read UWorld: Is Your Strategy Wrong? (I Scored 270 By Ignoring The Dogma), click here).

We want to believe we can control our scores by inflating our QBank percentages. Hearsay, and “score predictors,” reinforce the link between how many questions you get right and your final score.

Instead, in times like this, remember two things:

  1. Your goal is to do well on Step 1. Residency programs won’t ask you what your UWorld percentages were.
  2. The NBME – writers of Step 1 – states their goals clearly. They write“each item should assess application of knowledge, not recall of an isolated fact.”

Don’t ask how to maximize your QBank percentages. Instead, maximize how much you can integrate and apply.

3. Depth > Shallow Breadth

So you’ve used UWorld to address your biggest weakness. But what are 240-seekers to do next?

Once you identify a weakness, master the topic. For example, embryology was one of my most difficult subjects. For a while, I got every cleft lip/palate question wrong.

So what did I do? I learned enough about cleft lips/palates, so I’d never get another related question wrong.

Use an Electronic Copy of First Aid to Find All Related Information

To find as much related information as possible, use an electronic copy of First Aid (affiliate link). With an electronic copy, you can search for terms like, “palate” and “cleft palate.” Your goal is to find anything related to that topic that would be most likely to show up on your test. Then you should learn as much as I could on those topics. (To read more on how to master subjects and never forget them, read below).

USMLE Step 1 Cleft Lip

USMLE Step 1 Cleft Lip Palate


Mastering material takes more time than memorizing. However, the payoff of mastery is significant:

  • You learn in a way that is Boards-relevant
  • By putting them into Anki, you’ll never have to go back and re-learn anything
  • You will take better care of patients. (It’s hard to remember sometimes that our ultimate goal was to help real people).

(To read more about Anki, click here).

But once finding the relevant First Aid sections, how exactly do you develop mastery?

Use Other Resources to Develop Mastery

Med school bombards you with unrelated facts. However, what you do with those facts is up to you. When you’re tempted to memorize, do this instead:

  1. Ask (and answer) “Why?” Many of us read the same material. Only a handful will be able to spot the connections. Seeing the connections often comes down to asking “why?” and “how?” to focus your mind.
  2. Use other resources as a reference to find further explanations. No one resource has all the answers. First Aid is more of a high-level overview and lacks many details. For example, let’s say First Aid’s explanation of amyloidosis is lacking. You can try Goljan. If that doesn’t work, Robbins can contain excellent descriptions. Notice I say, “reference.” Once you’ve found your explanation, go back to doing QBank questions. You could spend all day reading any of these books. Reading Boards review books may help improve your knowledge. However, it does little for your ability to apply it to clinical vignettes.
  3. Ask a friend. My best friend and I had very complementary strengths/weaknesses. (He ultimately matched to the Hopkins neurosurgery program). I knew his strengths, and vice-versa. So when a question came up (particularly anything neuro-related), I knew who to call!

4. Make Connections, Then Anki Cards

It’s easy to read First Aid and assume you should memorize the facts. Burkitt’s lymphoma’s translocation? OK, I guess I’ll make an Anki card on that fact. Its response to chemotherapy? Yep, another card!

Making Anki cards to cram facts is a waste of time. So how do you master the material, never forget it, and crush your USMLE?

For each disease you learn, ask three simple questions:

  1. What is the pathogenesis?
  2. What is the presentation?
  3. How can I connect the two?

For example,

  • Don’t ask: “What is the translocation seen in Burkitt’s lymphoma?”
  • Instead, ask: “What is the translocation seen in Burkitt’s lymphoma, and how does that explain its presentation and response to chemotherapy?

(To answer the question, Burkitt’s is an 8,14 translocation. This translocation causes overexpression of the myc oncogene because myc’s expression is now driven by the Ig heavy chain promoter. Like all oncogenes, myc stimulates cell proliferation. Thus, myc overexpression explains why Burkitt’s lymphoma is a VERY rapidly-growing tumor. However, its rapid growth is also its Achilles’ heel. Traditional chemotherapy targets rapidly-dividing cells, so Burkitt’s is very responsive to chemo).

If you struggle to make these connections yourself, check out the Yousmle Step 1 cards. In it, you’ll find pre-made cards targetting students’ most significant gaps. You can master more in less time and maximize your USMLE score.

Similarly, if you watch lectures but forget them immediately, check out the Yousmle Online Course. Not only will you make connections, but with the integration/application questions you’ll never forget another lecture again. Check out the Yousmle Online Course here.

Free Master Anki Questions

What has worked for you or not? Share your experiences in the comments!

Photo by Element5 Digital.

  1. Sallydro says:

    Hello Alec! first of all I would like to say your blog is superb, filled with lots of helpful insight. and secondly I have a question, I want to ask you about how to review a question. I spend hours on a single block(it takes me a whole day sometimes), trying to go through every tiny detail and making flashcards, feeling as if everything is important. What would you suggest regarding this? thankyou in advance!

    1. Yousmle says:

      Hi Sallydro,

      Thank you for your kind words! Re: how to review a question, it’s hard to give much specific advice, since I can’t assess your background, etc. For example, maybe you never really learned much of this well, and so need to take a lot of time to master things – in that case, it might require that much time. Or maybe you’re burned out, and so you’re very inefficient. Or maybe you are a perfectionist and get buried under mountains of details. These are all reasonable possibilities, but without seeing how you work, I can’t give specific advice.

      I realize that might not help you much with your specific situation, even if it is true. That said, if you’re interested in a free consultation with one of our success specialists, you can sign up here:

      Dr. Palmerton

  2. Yara says:

    Hello! I’m a fresh graduate starting USMLE. I’m confused on doing uWorld parallel to studying FA. I feel like I will get all answers wrong anyway since my basic science was years ago. Should i, for example, study biochemistry, then do some questions to know my weak points, then revise them and so on?

    1. Yousmle says:

      Great question. It must be frustrating to be tested on so many things you studied long ago – or that your school didn’t teach you (if you were an IMG, for example). It’s hard to learn those subjects from scratch. If you were in the Yousmle Online Course, I’d recommend doing the biochemistry videos first, so you can have a foundation, then filling remaining gaps by doing questions and studying based on the things you miss. If you were not in the Online Course, I’d recommend doing questions and studying based on the questions you miss, although that can be very challenging if your foundation is weak for a particular subject.

  3. Aaron says:

    This doesn’t mention anything about what you will learn #3
    How I studied from UWorld and Kaplan to raise my score 34 points (from an initial NBME of 236 to my final score of 270
    Nothing about Kaplan here

  4. RTHYI says:

    Hi Dr. Palmerton,
    When I read any clinical vignette, the amount of information in there is overwhelming. Additionally, the symptoms, treatment options, and diagnostic tests become cluttered in my brain, without a clear, logical order.
    In this regard, I am intrigued by your pathogenesis to presentation concept. Could you elaborate further on whether/how it helps with diagnosing a patient from a vignette? Will it help with question interpretation?

  5. Ana says:

    Hi Alec! I am an international medical student and I just finished my 3rd year (out of 6). I am planning on taking Step 1 in September 2020 and want to start studying this summer, since I feel I lack a strong baseline for this test. I have used Anki for my Pharm course and Pathoma (only partially) before, but apart from that I am only used to memorizing facts.
    What should be my strategy to improve my knowledge?

  6. Farah Raza says:

    Is this subscription for free ??

  7. Ej says:

    Hi Alec, do you think its worth making anki cards on uworld minutae too? Thanks!

  8. Andrea D'Achiardi says:

    QUESTION- 9 pathogenesis and presentation cards. These cards seem to break the 3 rules b/c it has more than a single question per card and too much information in the answer. Is this different than the anki cards we are suppose to create?

    1. Yousmle says:

      It doesn’t really break the rule as long as the information is connected! Unconnected facts should be separated, though.

  9. sebastian valdivieso says:

    Hey ALEC,

    I hope you can help me with your advice.
    I bought your Anki deck for step 1 yesterday and I am going to start with it today.

    I scored 250 on NBME 13 4 weeks ago, today I scored 236 on NBME 15.
    I am done with 70% of Kaplan Bank with average of 82%.

    My target score is 260+ 🙂

    I am planning taking step 1 on September, so I wanted to finish Kaplan Bank and then doing Uworld.

    I am reading first aid for the second time, but I feel that I am just reading and repeating without a clear plan.

    What’s your advice, and the best strategy that you would recommend?



    1. Yousmle says:

      Fantastic question. The biggest thing I would suggest is to focus more on trying to understand disease processes rather than having a set number of pages in a particular book that you want to read. For example, most students typically focus on learning everything in a particular book, then moving on to another. Instead, I would focus on learning the disease process, and using whatever resources you have available to do that. That way you can structure your day in a more predictable manner, focusing on learning a particular number of diseases or topics during the day, rather than trying to read some predetermined number of pages.

      If you’re interested in streamlining your process of question interpretation, you can sign up for group tutoring:

      Just focus on one problem/disease at a time, don’t think about the number of pages of a book you’re supposedly supposed to read, or all of the crazy/misguided advice you will read online.


  10. inam says:

    hi Alex,
    is it possible to study the step 2 medicine cards by subject?
    I cant seem to separate them by subject. I feel like there must be a way.

  11. Firman Sandiyah Budi says:

    Hi Alex… I barely know how to use Anki. Would you please show me how to download your Flashcards??
    I’m an IMG, i’m now in my clinical years and will take my exam on april next year. How to overcome anxiety?

    1. Yousmle says:

      You can find the cards here:

      Here is how to upload them:

      It’s hard to give specific advice about anxiety without knowing the cause. I know many students have used journaling, exercise, seeing a counselor, as ways to help with anxiety.

  12. mohammed says:

    hello i have a problem
    my score in my first nbme 12 was 170 then after 2 months i took nbme 13 my score is 200 after 1 month i took UWself assessment 1 my score is 206
    my exam is in 2 months
    any chance to get +235 in the real one !!
    thanks in advance

    1. Yousmle says:

      Sure, there is a chance, it will depend heavily on how effectively you learn, and even more importantly, how effectively you learn how to apply you knowledge to questions/interpretations of vignettes.

  13. Farah Kaier says:

    I am planning to start my prep soon and I like this idea of yours better. But, I am confused as to which Qbank to start with. Should I start with Kaplan for my first reading or Uworld directly ? Please advice! Thanks

    1. Yousmle says:

      I’d do Kaplan first, then UWorld, if you have time for 2 QBanks. If just one, I’d do UW.

  14. Karim Elkholy says:

    Hey ALEC,
    I find Your Sharing is very helpful,
    I scored 215 on NBME 15 2 weeeks ago, today i scored 220 on NBME 13, done with 70% Uword qbank *random, timed* score average is 68-70 %

    My target score is 240+
    Exam In almost 2 months
    What’s the best strategy ?

    1. Yousmle says:

      I responded to this on two separate other posts. Please read my response there.

  15. alexroussos says:

    Hey!! Great read! So, I have my exam in about 6 months. We just started our second semester of 2nd year and I’ve begun my review. Do you still think it is feasible to make an Anki deck? Lastly, I noticed you make cards for diseases in a very specific way, but do you make cards for straight up facts? Like “where is Ach synthesized?” “Basal Nucleus of Meynert.”

    1. Yousmle says:

      Thanks so much! Definitely still possible, although you have to be careful to not overload it. The tendency is to try and put everything into it – instead I’d focus on just trying to not lose anything you’re learning currently, or anything you’ve reviewed. I also make straight cards, as you mention, although try to relate them to other things/concepts as much as possible.

      Best of luck!

  16. Stacy says:

    Hi Alec!
    1.What do you do before making the Anki cards? Do you read the chapter and highlight or read while copy pasting stuff to Anki?
    2. How long does it usually take you to make a deck for 1 chapter?

    1. Yousmle says:

      Great questions. Typically, I would go to lecture, then make sure that I learned the appropriate information in First Aid about that topic afterwards.

      It can take quite a long time to make cards on a single chapter. I would give myself at least 3 to 7 days, depending on how well I knew the information to begin with. This is just a rough estimate, though, and will depend on each situation.

  17. Sniki says:

    hi Alec,

    So I have been reading your website and your posts, you are a pretty big advocate for Anki. My question is, how do you find the time to make so many flashcards, and then review all of them, meanwhile still keeping up with your classes, and doing Qbanks. Could you maybe give a timeline or perhaps how you allocated your time in a given week /day. I’m an OMSII in the first semester, and trying to learn how to do things for next semester. Even now if I make quizlet cards, its so hard to find to make good cards, and then to make sure I go back and review them, meanwhile, keeping up with other material/lectures. Because I need to read the book or look up extra details as well when studying, simplyfing reviewing flashcards doesn’t always help.

    1. Yousmle says:

      Great question. Honestly, I did very few questions during my preclinical years, prior to starting my dedicated study period. I’m working on a more detailed post on a daily schedule, but for now, suffice it to say that my goal for each day was to master the topics that were covered in class, and to hold on to the things that I learned previously by using spaced repetition. Anything beyond that, I saved for later, including question banks.

      1. Sniki says:

        Yes please share your timeline that would really help! Because I will be almost done with first semester of OMSII and I want to figure out what my plan of action should be after Christmas.

  18. Selena Baros says:

    Hi Alec,

    I’m taking the Step 1 at the end of October and I just a few quick questions regarding your Anki card set that I purchased:

    1. Do you suggest making 30-40 cards of my own (for my weaknesses) along WITH studying 30 cards from your set daily? OR just study your cards (30/day)
    2. How efficient does this study technique sound, unit based initially and then random (since I don’t feel confident with the material): Do a set of UWorld Q’s, go over my weaknesses with First Aid, then do the corresponding unit of Anki cards from your set for the day?
    3. Does your Step 1 set of cards include all pharmacology and microbiology? Or do I have to make my own?

    Thank you for everything!

    1. Yousmle says:

      Hi Selena,

      1) I’d recommend making perhaps 15-20 of your own cards, in addition to the 30/day of the cards. You’ll have to be efficient, and focus mainly on the information in the educational objectives/FA, without making super long cards.

      2) That sounds very reasonable. I typically recommend subject-based initially, particularly if you are < 200 on your NBMEs.

      3) It includes some pharm and micro, but it limits the number of cards so that it is not overwhelming. My pharm deck is still available for a limited time here:

      Best of luck!

  19. Fahad says:

    Hello, I want to purchase Anki, but I almost have finished UW Qbank (35% remaining). I will have the exam in next couple months. What should I do now? Thank you.

    1. Yousmle says:

      Hi Fahad, thank you so much for the question. You still have a great deal of time before your exam – I’ve seen students improve their score by more than 70 points in less than that period of time. How you use your time will be critical. If you start doing the cards now, you can complete all of them at a relatively relaxed pace. I’d recommend in your case doing 30 new cards a day from the deck, while making 15-20 new cards a day of your own to target additional weak areas.

      Hope this helps!

      1. Fahad says:

        Thank you for replying.
        I read your articles a lot and it seems complicated for me and can’t get the your method in simple lines.
        Kindly, may simplify you method and put it in order?

        Appreciate your help and support.

        Thank you again.

        1. Yousmle says:

          Thanks so much for your e-mail. If I had to simplify, I’d say, 1) learn things well. Focus on the pathogenesis to presentation cards. 2) Use spaced repetition to never forget the things you’ve learned well. 3) Apply your knowledge to understand each sentence of each question stem.

          Remember, the goal is to learn things so you can apply it clinically. Try to understand, and learn how to USE the knowledge.


  20. mythri says:

    Hey alec,
    I feel like i have done everything and although it helped me out a lot, I’m not where I’m supposed to be. I have never taken step 1 i have only taken the COMP ( comprehensive basic science exam) and my last score on it was a 59% which is equivalent to a 175 on the real thing…. which is still not passing. (even though i jumped from a 140 to 175, i have far to go, and i have taken many review courses 1. kaplan, 2. Eagle program 3. private tutoring 4. a review course in atlanta (2x) but i feel so stuck and don’t know where to start, i want to use pathoma, Dr. najeeb lectures, but as i was reading your articles its really passive and i only have about 3-4 months to study. I still don’t understand
    1. how to use first aid
    2. how to use my questions to get where i needed to get
    and i have taken all of the nbme and gone over them… and i remember the answer to them so i think thats why its not really accurate.
    if you could help me out with this it would be great..
    do you think 3-4 months is enough to increase another maybe 20-30 point increase?
    Thanks a lot

    1. Yousmle says:

      Good questions. I’ve addressed them here:

      How to use First Aid:

      How to use QBanks:

      Reasonable timeframe for a 20-30 point increase:


  21. Jose Ting says:


    I wanted to know what you thought about firecracker, and how it compares to your anki deck. Feel free to use this question on your website.


    1. Yousmle says:

      Hi Jose,

      I never really used Firecracker much, so it’s hard for me to comment. From what I understand and from what I’ve seen from my short time using it, it focuses on trying to teach you everything you could possibly know, which can often overwhelmed students. Also, at least the cards that I saw focused more on basic, rote sorts of learning, rather than higher-level integrations, which is what I have spent so much time creating.

      Hope this helps!


  22. tc28 says:

    Hey Alec,

    I am about to start my 7 week study block for Step 1. I have a good foundation of all the material from my biomedical science classes in my first 2 years of medical school. During my study block I want to get through all of first aid, but I don’t want to just passively read/memorize information and forget the information a week later. I have already been doing UWorld questions throughout this year and going to FA to read up on the disease/process when I would get the question wrong.

    After reading your blogs/posts I think I’m going to make anki cards for the questions that I get wrong in UWorld and try to review them everyday. However, I’m still stuck with how I should do FA. Should I make pathophysiology to presentation cards for each page in FA? Or would it be more time efficient to use the ones you have already made? I’m worried that the act of making the card is key to learning the material. I’m worried that purchasing your cards would essentially be purchasing another Firecracker program. Did the students who have seen their scores jump tremendously use your cards solely? Or did they make their own? Or did they do a 2/3 yours and 1/3 theirs?

    My current plan is to do about 76 UWorld questions per day and go through each section in First Aid, devoting about 2-3 days per section. Is this a good plan, and how should anki be integrated into this?

    Thanks for all of your advice. I’m torn because I have seen other students at my school who have made 240+ without using a program like anki. Anki definitely is not the stereotypical study method, but maybe it should be.

    Hopefully you can shed some light on my dilemma.


    1. Yousmle says:

      Hey TC,

      I think you are asking some fantastic and insightful questions. I agree that in general, making your own cards can be of great use. I don’t think that using someone else’s cards for everything is the way to go. However, having used Anki, and made tons of mistakes both in how I was making my cards, as well as how it was learning the information and putting it together, I found that the best approach is a hybrid approach, where you can use someone else’s cards to get you started, particularly for some of the most difficult aspects of a particular topic, to give yourself a strong baseline, that you can then use to make your own cards. The goal of the Step 1 Anki deck, is to provide the highest quality pathogenesis to presentation cards, to speed up your own learning, as well as to give you templates for making your own pathogenesis to presentation cards for things you are learning on your own!

      Thank you for your great question, and I look forward to hearing from you again soon!


  23. Chris Tan says:

    Hi Alec. I want to start by thanking you for all the helpful advice you have given in your website and the emails. They are packed with a lot of useful tips. I am an IMG and graduated in 2012. I took the step 1 over a year ago and was devastated with such an extremely low score so I bucked down and tried to force myself to study without much progress. I realized my fundamentals were not as solid as I had originally thought. I had recently taken to volunteering at a clinic to gain some insight and a change of pace. However I am planning to retake the exam this summer. I plan to stop the volunteering to focus solely on my studies, but was told to just decrease the number of days instead.

    Your email regarding focus made me realize that I will be reducing my potential study time, but at the same time I am also gaining experience that can help tie in the information I have learned thus far. What would you advise?

    Thank you.

    1. Yousmle says:

      Hi Chris,

      Thank you so much for your message, and for your kind words. I had responded to this a while ago, but I don’t know if it got lost in the interwebs or just wasn’t displaying. Clinical experience can definitely be a useful thing as you point out, but the question is, is it worth it to take time out of your day, to gain that experience if it means studying less for your exam. I don’t know that there is one right answer, but I would say if it were me, I would probably focus more on my studies, since generally, most of the volunteer type experiences probably will not yield the same value as dedicated study. I would be interested to hear what other people think, but that would be my first thought.

      Hope all is well,


  24. Matthew So says:

    how do you make flash cards based on educational objectives?

    1. Yousmle says:

      Make a question so that the information in the educational objective is the answer. You can use the Step 1 deck as examples, or any of the cards on the site, as well. I’ve also written several articles on Anki best practices as a guide!


  25. Asad Choudhury says:

    Hi Alex, I have the 2014 version of First Aid for Step 1. However, the 2015 version has come out and I am taking Step 1 in 2015. Do you recommend that I stick with the 2014 version or should I get the 2015 version and use that? Is it important to use the latest version of First Aid? Thanks!

  26. Junior Adeyemo says:

    Hey Alex!

    Your site is awesome and I’ve learned a lot so far. Being a novice anki user, I did have a question for you. I usually have my blocks in a span of 4 weeks and I was wondering what settings to use or adjust to sort of maximize my learning for all the material in the block. Because I feel that the current settings maybe not be ideal for being fully prepared for a 4 week block. Thanks.

    1. Yousmle says:

      Hey Junior,

      Thank you so much for your message! I think the issue you might be running into is having so many cards built up, and then having a ton of cards from your previous block that you have to do while you were learning new material. My suggestion would be to try to create a manageable number of cards every day, by focusing on making pathogenesis to presentation cards. The more basic simple fact cards you make, the more they will build up. I typically tried to make roughly 40 to 45 cards in a day, and never really added that many more cards per day than that.

      Hope this helps!

  27. Elvina Lingas says:

    Hi Alex, I have purchased your Anki flash cards and have been using it for a week or so. I have been taking Kaplan class (I’m an IMG) and I still have 3 more months for my allotted prep period. I found your cards are very well made,not just simply stating facts but also concepts, and they have helped me like a mini quiz as well. I agreed Step 1 FA is difficult to study from; and I was so bugged out at first when everyone seemed to be studying from First Aid while I could not grasp the chapters despite having gone over them several times.

    1. Yousmle says:

      Hi Elvina,

      Thank you so much for your kind words!! It makes me feel very good to know that you’ve found the cards so well made, and that it has helped you learn/retain concepts and not just facts. I appreciate your honest feedback, and welcome any suggestions you have for improvement of the cards!!

      Take care,

  28. Casey Dye says:

    Great information. I just finished step 1 and wish I had found this blog and spaced repetition earlier. Now that I am moving on to clinical rotations and step 2, can you give some advice on how you used anki in your 3rd and 4th years.

    1. Yousmle says:

      Great question, and one that I get a lot. I hope to publish an article on this in the coming weeks, but in general, my approach was VERY similar to what I did for Step 1. I used USMLE World qbank, and did questions FIRST before reading, and then made sure to study from the educational objectives on stuff I got wrong. I didn’t use Pretest/Case Files/other books much, although I used MKSAP for internal medicine, and uWise for Ob-Gyn.

      I hope to have more specific advice for you in the coming weeks! Thanks again for the question!

  29. Sidney Phillips says:

    I like your suggestion of using Anki to annotate facts. When I do Uworld I used to keep a separate notebook, but this took a lot of time writing things out by hand. However, now I annotate directly into Cerego. Cerego is a free website that uses an advanced spaced repetition algorithm backed by academic research. The other nice thing is Cerego offers a free ios app. Great website thanks for all the tips you provide.

    1. Alec Palmerton, MD says:

      Hi Sidney. Thanks so much for the comment, and the info! There has been a proliferation of spaced repetition programs, and I had actually never heard of Cerego. Out of curiosity (and for the benefit of the readers of the blog), what would you say the pros and cons of Cerego vs. Anki? Why did you choose Cerego vs. Anki?

      1. Sidney Phillips says:

        I chose Cerego over Anki because it was easier to get up and running and it has a more advanced spaced repetition algorithm. I don't know how Anki is on the PC, but on the Mac the interface is cumbersome. I don't have to worry about any settings; all the features of Anki are in Cerego plus more. By more, and this in my opinion is the main advantage, the Cerego algorithm determines which cards you need to review (I think somewhere on the Cerego blog it mentioned it uses variables such as whether you got the card right or wrong and how much time it took for you to answer). Frankly, I'm not sure how much of an improvement the Cerego algorithm is over the one in Anki, but I saw the founders were academics and a company like Elsevier also backs it, so it seemed legit. The free iOS app was also a selling point for me.

        As for cons, It is cumbersome to go and find a specific card, as I don't think there is a search function at the moment.

        1. Alec Palmerton, MD says:

          Interesting! I think you're probably right that the algorithm is pretty similar across the various platforms (that's been my experience looking at Anki vs. many of the others – I know Anki at least takes into account the number of times you get something wrong, although am not sure about whether it takes account the amount of time it takes to answer the question), but it's fantastic that it's completely free, including the iOS app. That's huge, because even though the app is amazing for iOS and I consider it well worth the investment, it's still quite expensive ($24.99 when I bought it). It does sound like one of the major benefits of Anki is it's search function, which makes referencing any of your previous notes super fast. Clearly there is no perfect program out there, but it sounds like you've got a pretty solid method.

          Out of curiosity, what kinds of cards do you make? Is it mainly "flashcard-type" cards, longer ones that force you to tie in information across subjects, or something completely different? I'm always curious to see how people use spaced repetition!

          1. Sidney Phillips says:

            I tend to make short fact cards and would rather split up an associated set of details into multiple cards. Sometimes I'll put the exact Uworld vignette with just the essentials. Rarely, I'll do a more dense card like "Name the 3 mechanisms how PTH increases serum calcium". The one thing about Cerego that I have to keep in mind when creating cards is that the algorithm automatically includes the reverse fact when quizzing so I have to make sure that the facts make sense from either direction.

            If you get a chance try a short trial run on Cerego and let me know what you think. The company seems to be receptive to suggestions, so I hope they implement a search function soon as many users have requested.

          2. Yousmle says:

            I completely agree overall – dense cards with too many facts (or even worse, lists!) are huge time-killers, and I never found them very effective.

            In addition to breaking things down into shorter cards, one thing I found helpful and super efficient was to make what I like to call “Pathogenesis to Presentation” cards. It’s what some people would call a “story” – basically, it’s a way to weave together a bunch of facts together in a way that you won’t forget any of them.

            A basic example would be epidural vs. subdural hematomas. Most people using Anki/Cerego would simply make 8-10 cards like, “what is the pathogenesis of epidural vs. subdural hematomas?” and “what is the general time-course of epi vs. sub” and “which can cross the falx?” It makes sense to do this – if you tried to memorize all of those facts in a single card, it’d be impossible.

            You seem like a smart guy, and are probably much better with retaining large amounts of information than I am; I always had difficulty remembering so many disparate facts. However, when I wove them together into a story, and connected them together, I was able to recall all the facts much better.

            For example: epidural hematomas involve the middle meningeal artery, whereas subdurals involve the bridging sinuses. Arteries have greater pressure, so when they bleed, an epidural hematoma would progress more quickly. And since the falx is a fold of dura, epidural can cross, but subdural can’t.

            When I did this, I found I had to make fewer cards (that single card contained all of the facts I had been trying to memorize previously), and I remembered them better. Instead of making the 6 cards I’d have to do (and which Cerego might make you do, since it reverses the cards automatically!), I’d only have to make a single card to recall all of those facts, simply because I created a narrative.

            What do you think? It took me a while to come to this idea, and I probably didn’t do the idea justice.

            Also, I definitely want to check out Cerego when I get a chance. I’m always on the lookout for things that might be helpful!

          3. Sidney says:

            Your idea of keeping a story in mind is something similar to what I do. I also use Picmonic, which has crazy stories made up for most USMLE topics.

            Unrelated note, I also had been using Self Control to shut down all unnecessary websites. For even more fine tuning of time there is a free website called that will keep track of your web surfing and then give you a weekly productivity score. It’s an easy way to see how you’ve spent time online. I use the Pomodoro method and a Mac program called Vitamin R2 to divide my study time into 25 minute chunks. I think I must have ADHD because I need all those tools to keep me on track even though I’m studying for the most important test of my life!

          4. Yousmle says:

            Wow, Rescuetime is awesome! This is great – exactly what I’ve been looking for, as I’ve always been curious to see how much time I waste every day (lots, I’m sure).

            I had such huge issues with unnecessary websites, even for Step 1 studying. Seems like you’re doing a great job of utilizing your time given the circumstances, though! When is your test?

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