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Nailing the USMLE Step 1 Fundamentals (#4 Helped Raise My Score to 270 from 236 First NBME Practice Exam)

Guide to Mastery of Topics for the USMLEs

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by Alec in Plan
Federer USMLE Step 1 Fundamentals

If you’re like most medical students, you’re probably wondering how to best prepare during medical school and how to improve your NBME practice exam scores in the most efficient way possible to ace the USMLE Step 1.  Here is a message I received recently from a student preparing for Step 1 (all identifying information has been removed for privacy).  I have included an abbreviated version, along with my response here.  Here, you will learn:

  1. How First Aid for the USMLE Step 1 is written, and how you can use this knowledge to your advantage
  2. How I studied from QBanks to raise my score 34 points (from an initial NBME of 236 to my final score of 270)
  3. My simple trick to reading First Aid to let me know exactly whether I had learned a topic well or not

Here is the message:

Hi Alec,

Thank you for this email. I actually am taking 6 weeks to study for Step 1, and I would most certainly like to know more about how to work in resources studying for Step 1 and how you recommend that I study in general in order to do well. My dream goal is 245.

What is the best way to nail down the fundamentals to prepare for this exam?

Thank you,

My response:

Dear L.,

That’s great to hear that you will have 6 weeks of dedicated study time. As far as fundamentals, it is not easy, but you have the right attitude: working assiduously to make sense of as much of the pathophysiology as you can.  As anyone will say, you will have to use First Aid and USMLE World. The question is, “how?”

Most students prefer to read First Aid FIRST, then use USMLE World to “test themselves” on the material. In other words, they will read the cardiology section in First Aid, then do cardiology questions from their QBank.  While this is logical, and has been done by many students, I don’t like this approach for two reasons:

  • First, if you don’t know the material solidly in the first place learning from First Aid is painful, and highly inefficient.  In other words, if I know antiarrhythmics well to begin with, reading through First Aid is a great way to refresh my memory.  However, if I’m weak on the details, using First Aid alone is a very difficult impossible way to gain that fundamental knowledge.  While the explanations have improved over the years, First Aid is still basically condensed facts you need to know for the exam, and is not conducive for having an integrated understanding of the material.
  • Second, we often (mistakenly) convince ourselves that after “reading” over a paragraph in First Aid that we know it. However, when actually forced to apply this information in a QBank question, our knowledge fails us.  This is because since learning new material from First Aid is so difficult, we often resort to memorizing the words on the page (again, learning from First Aid is painful). Then, after we’ve gotten a question wrong and are reading through the question explanation, we have to go back to First Aid, and re-learn the facts in the first place while reading through the USMLE World explanation, reduplicating what we’ve already done.

Instead, I recommend the following:

Federer USMLE Step 1 Fundamentals

Master the fundamentals like Roger Federer, and prepare to dominate the USMLE Step 1.

1. Understand how First Aid for the USMLE Step 1 is created

So many people follow the dogma that “all you have to do is learn First Aid,” but few actually stop and consider how it’s made.  Although I can’t give a first-hand account, I can tell you a story told I heard from an attending who had attended Yale (where First Aid was originally created), who told me how they created the book.  If true (and I have no evidence to the contrary), his explanation helps elucidate both the beautiful simplicity with which the book is made, as well as how we should use it.

He told me that they approach students who have taken the test, and simply ask them what questions were on it.  Obviously, other organizations do the same thing (Doctors in Training comes to mind), but what First Aid does with that information is key: they simply write the answers to those questions, or at least the information you would have needed in order to answer the question.

In other words, the information in First Aid is a compilation of all of the raw information you would need to answer the questions remembered by people who have taken the exam.

This explains several vexing problems experienced by most people who study for Step 1, including:

  • Why there doesn’t seem to be a particular order/flow between topics (now we know this is logical, since the goal is simply to give us an idea of what is being tested, and what kinds of facts we might need to know)
  • Why even within each topic it seems to be a jumble of mixed facts (it is written that way)
  • Why students struggle to apply what they’ve learned from First Aid to QBank/Step 1 questions (the First Aid approach emphasizes facts > understanding), and finally
  • Why First Aid is so hard to learn from (again, the goal isn’t to teach, but rather to give you an insight into the kinds of questions asked/information required)

I know you’re probably thinking, “That’s great, but how does this help me study for Step 1?”

…while First Aid is a collection of facts tested on Step 1, you will be expected to apply and integrate those facts.

Since the USMLE Step 1 is going to emphasize the application and integration of knowledge, my goal was to understand the mechanisms of disease, and move beyond the simple memorization of “facts,” no matter how “high yield” they are.  I tried to learn “why?” and “how?” rather than, “what?”  If you get nothing else from this, remember that while First Aid is a collection of facts tested on Step 1, you will be expected to apply and integrate those facts.

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, and so that it can lead to the opposite downstream signaling.  It’s not enough to memorize that calcium channel blockers extend the PR interval; instead, understand that Ca++ is the dominant ion used in conduction because you lack IK1 channels in nodal tissue, so that Na+ channel inactivation can’t be removed (to learn more, click here).

2. Diagnose your weaknesses by doing QBank questions first, treat with First Aid later

If we think of our lack of knowledge as the illness and First Aid/QBank question explanations as the treatment, we are much better served by having a clear diagnosis of what we don’t know first, before we seek out specific remedies.  A huge challenge for Step 1 studying is knowing how to best apportion our time.  Without a clear goal of what we’re trying to learn, many students have spent hours poring over First Aid, without having a clear purpose other than a vague, “I’m supposed to get through the genetics section today.”

Generally, I learned more in a given hour of studying if I first did QBank questions first, then read the First Aid explanations later.  Obviously, everyone is different, and you may be one of the exceedingly rare people who can learn a lot of new material by simply reading First Aid cover-to-cover, but for the rest of us, that is usually not the case.  I found my mind was much more engaged and that I learned much more from First Aid when I had just gotten a question wrong, had misinterpreted the meaning of a particular physical exam finding, etc.  After being mistaken, I had questions, and was seeking answers in First Aid, rather than simply reading through First Aid sequentially.

An additional benefit is that, with the explanation from USMLE World, I could make more sense of First Aid, which helped speed up the process, as well.

“But won’t I get more questions wrong in USMLE World this way?”

Yes, you probably will, but the goal for me was never to get a high USMLE World percentage.  It’s enticing to believe that we can somehow control our scores by inflating our QBank percentages, with this idea reinforced by the proliferation of “score calculators” online offering to predict our scores based on the % correct in a given QBank.  However, I would posit that the most important goal is apply and integrate as much knowledge as possible during your Step 1 exam, NOT to maximize your QBank scores.

How you accomplish this goal is up to you, but I found that I learned this application/integration much more effectively by beginning with QBank questions.

3. Favor depth over shallow breadth

…my goal was to invest the time in that topic that I would never get another related question wrong, and recall that information indefinitely by putting it into Anki.

When I discovered a weakness (and there were many), my goal was to learn as much about that topic as possible.  For example, one of the hardest topics for me was embryology.  After getting several questions wrong, consecutively, on cleft lips/palates, my goal was to invest the time in that topic that I would never get another related question wrong, and recall that information indefinitely by putting it into Anki.

To that end, I used an electronic copy of First Aid (aff link), searched for the terms, “palate” and “cleft palate” to know what kinds of information people who had taken the test were expected to know, then learned as much as I could on those topics.

USMLE Step 1 Cleft Lip

USMLE Step 1 Cleft Lip Palate


Even though I might make it only through about a page or two of First Aid, I knew that by having greater depth it would facilitate future studying.  Plus, by making integration questions and putting them into Anki, I would never have to re-review that information.

4. Make Master Anki Cards: Learn to connect, reference accordingly

At the risk of being a broken record, the USMLE Step 1 exam is a test of integration and application of knowledge rather than a test of how well you can memorize.  To that end, I used this simple trick to help focus my studying on relevant information, as well as to know whether I knew a topic at sufficient depth.  For each disease I studied, I asked three simple questions:

  1. What is the pathogenesis?
  2. What is the presentation?
  3. What is the connection between the two?

From this information, I would then generate Anki questions that would explicitly test/reinforce this information.  Instead of simply asking, “What is the translocation seen in Burkitt’s lymphoma?” I would 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, involving overexpression of the myc oncogene, since it comes under the influence of the Ig heavy chain promoter.  Like all oncogenes, myc drives cell proliferation, and so myc overexpression causes Burkitt’s lymphoma to be a VERY rapidly-growing tumor.  However, since it is so rapidly-growing, and since traditional chemotherapy targets rapidly-dividing cells, Burkitt’s is very responsive to chemo)

Anki is a spaced repetition program…that happens to use flashcards.

Most people think of Anki as simply a “flashcard program that uses spaced repetition.”  I disagree.  The beauty of Anki is that it uses spaced repetition so that you will never forget something you’ve learned.  It is a spaced repetition program…that happens to use flashcards.  If there was one thing that I was proud of in my preparations for the USMLE Step 1, it was that even though often I was only taught a simple fact, I worked hard to understand why that thing was.  Here are some tips I used:

  1. Look for explanations.  This may seem obvious, but there were many times when I would read the same QBank explanation as a friend, but only one of us was able to explain the connection between pathogenesis and presentation.  Just reminding myself to ask, “why?” and “how?” often helped to focus my mind on the keys I was seeking.
  2. If you can’t find an explanation, seek explanations out in other resources as a reference.  These include, but are not limited to: Yousmle USMLE Step 1 Cheat Sheets (I couldn’t help myself from plugging the site!), Goljan, Pathoma, Wikipedia, BRS Physiology/Costanzo Physiology, or even Big Robbins.  For example, I couldn’t find a satisfactory explanation for amyloidosis in First Aid, and couldn’t understand it from the QBank explanation.  Thus, I went to first Goljan, then eventually settled on Robbins to understand the underlying basis for the disease.  Notice I say, “reference”; once I found my explanation, I went back to doing QBank questions.  You could spend all day reading any of these books, which may help improve your knowledge, but does little for your ability to apply it to clinical vignettes (the best way to learn to apply it is to do it in QBank questions).
  3. Ask a friend.  Seriously, my best friend and I had very complementary strengths/weaknesses.  I knew his strengths, and vice-versa, and so when a question came up, I knew who to call!

Free Master Anki Questions

Obviously, these tips are not exhaustive – what other ideas do you have?  What have you done that didn’t work?  What has worked that you could share?

What to do next:

  1. Download Anki if you haven’t already
  2. Start basic: read the article on how to create basic Anki cards
  3. Secure an electronic copy of First Aid
  4. Choose an article from the Table of Contents to test your mastery of Step 1 content (or read one on RNA viruses)
  5. If you found this article helpful, please consider sharing it with someone in their first two years of medical school, and leave a comment below!
  6. Like us on Facebook, or stop by and say hi! (I promise I’ll respond)

Photo by Tim Schofield.

Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored 270 on the USMLE Step 1 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.