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



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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 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

Curious to see exactly what I mean by a “pathogenesis to presentation” card?  Want to augment your Anki deck with cards I used to score 270 on the USMLE Step 1?  I’ve prepared 9 examples of higher-level cards just for youall you have to do to access the spreadsheet is support the site below!  Just copy and paste into your own deck!

9 Pathogenesis to Presentation cards in spreadsheet form


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.

  • Sidney Phillips

    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.

    • Yousmle

      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?

      • Sidney Phillips

        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.

        • Yousmle

          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!

          • Sidney Phillips

            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.

          • Yousmle

            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!

          • Sidney

            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!

          • Yousmle

            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?

  • Casey Dye

    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.

    • Yousmle

      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!

  • Elvina Lingas

    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.

    • Yousmle

      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,

  • Junior Adeyemo

    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.

    • Yousmle

      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!

  • Asad Choudhury

    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!

  • Matthew So

    how do you make flash cards based on educational objectives?

    • Yousmle

      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!


  • Chris Tan

    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.

    • Yousmle

      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,


  • tc28

    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.


    • Yousmle

      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!


  • Jose Ting


    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.


    • Yousmle

      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!


  • mythri

    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

  • Fahad

    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.

    • Yousmle

      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!

      • Fahad

        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.

        • Yousmle

          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.


  • Selena Baros

    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!

    • Yousmle

      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!

  • Sniki

    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.

    • Yousmle

      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.

      • Sniki

        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.

  • Stacy

    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?

    • Yousmle

      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.

  • alexroussos

    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.”

    • Yousmle

      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!

  • Karim Elkholy

    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 ?

    • Yousmle

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

  • Farah Kaier

    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

    • Yousmle

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

  • mohammed

    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

    • Yousmle

      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.

  • Firman Sandiyah Budi

    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?



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