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

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.

Want FREE Cardiology Flashcards?

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