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7 Most Commons Reasons Your NBMEs Aren’t Improving (And How to Fix Them)

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by Alec Palmerton, MD in Plan
Memorizing USMLE

You’ve worked so hard, but your last NBME was disappointing. So you hit your weak areas, re-watched some videos, and did QBank questions. But…your scores aren’t improving. You’re not anywhere near where you want to be.

You’re doing everything your classmates told you. You braved the message boards to get advice from anonymous Redditors. You even got a tattoo of UFAP (+ Sketchy) on your ankle. (Just kidding…I hope).

Unfortunately, if impressive USMLE scores were that easy, everyone would get them. Does that mean you’re doomed to low USMLE scores?

No! However, the reasons your USMLE scores are stuck aren’t what you are thinking. Instead, they’re likely persistent mistakes you’re making every day. Errors that can waylay even the best-laid plans.

I have helped countless students improve their USMLE and Shelf scores, both in tutoring and in the Yousmle Online Course. Often, we customize a plan to help them achieve realistic goals within their timeline. In assisting students in maximizing their USMLE scores, I’ve found many commonalities.

Here, I lay out the 7 most common reasons I see that NBMEs aren’t improving.

(To read my guide to the NBME self-assessments, click here.)

1. Memorizing, Not Mastering

By far the most common reason for students scores to stall is that they don’t understand the material. A lack of understanding of content is almost always the reason that students can’t pass Step 1.

“But I’m a med student. We’re supposed to memorize!”

The stereotypical med student may be a memorizing robot. However, to do well on the USMLEs, memorization will only hurt you.

How do I know? Because USMLE questions are designed to weed out memorizers. Gone are the days when you could scan a problem for “buzz-words” and see the answer.

Instead, the National Board of Medical Examiners (NBME) uses clinical vignettes. Why? Because vignettes allow them to see if you understand the material, or crammed it.

Don’t believe me? Here are the instructions to USMLE question-writers. They state, “Each item should assess application of knowledge, not recall of an isolated fact.”

Here is a sampling of other direct quotes from the NBME on the importance of testing application:

  • “Questions should NOT focus on the direct assessment of isolated facts.”
  • “Avoid asking about the leading cause of death in some subpopulation; instead, focus on the application of this knowledge.”
  • “The NBME decided that it was not important to assess whether students know definitions; instead, the goal became assessment of whether or not test-takers could apply ethical principles on their decisions related to patient care.”

I could go on.

So why do students persist in memorizing for exams? Because for most tests we’ve seen, memorization works. Most medical school exams test recall of random facts. This is true in the US, and especially true abroad.

However, memorization for the USMLEs is the wrong approach. It’s like doing pushups to train for a marathon. You’ll work hard, but you’ll never see any results.

Memorizing USMLE

Memorizing for the USMLE ultimately leads to frustration

What is the solution to over-memorizing? We need to learn the material well. To read more of how to master content, I recommend starting with the following articles:

2. Moving too Fast

You’re in your dedicated studying (or getting close). A mountain of material has accumulated to review. What do most people do? They start trying to move through the content faster!

The problem with moving too fast is that you don’t have enough time to understand the material. If you’re weak at cardiology, spending 2 days skimming First Aid isn’t going to be enough.

But what if you don’t have 5-7 days to spend on every topic?

First, consider asking your school for an extension. Most schools will allow you to delay when you take your exam, particularly if you’re at risk of failing. If you can have more prep time without delaying graduation, I’d strongly consider it.

But what if you can’t have more time? In my experience, I’d rather understand 60% of First Aid than have skimmed 100% of it. In other words, what I learn, I want to learn well. For the rest, I’d do QBank questions.

For example, let’s say I wanted to cover “everything,” but I only have 6 weeks left. I’d choose my three weakest subjects, and study them more in-depth. (e.g., 5-7 days each). Your weakest subjects are likely to be the ones where you can gain the most points. By focusing on those, you can improve your score the most in the shortest time.

Then for the remaining subjects, I would do mixed question blocks. For topics that I get wrong, I would master. Typically I recommend mastering 3 topics a day. Study more subjects, and you won’t have time to do questions. (More on this next). Study less, and you won’t really be learning enough information.

Wouldn’t it be best to have mastered everything from the beginning, and used Anki never to forget them? Absolutely. But if you’re stuck with the choice of cramming First Aid or mastering parts of it, I’d choose mastery.

3. Forgetting Old Material (Not Using Spaced Repetition)

If you watch a video, how long does it take you to forget it? If you’re like me, it’s usually a couple days. Same for reading a passage, taking notes, or even doing questions.

Long-time readers know that I’m a HUGE fan of spaced repetition. Why? Because if you’re NOT using spaced repetition, you’re forgetting your hard-earned knowledge.

This isn’t theoretical. There is a real limit to how high your score can go if you’re forgetting as much as you’re learning. Take this student, who had been studying off-and-on for years, and whose first NBME was 136. After learning to master material, and use Anki effectively, she improved her score by 101 points in about 6 months. (LINK HERE)

To learn more about Anki, click here.

To see the Yousmle Anki cards, where you can master topics AND never forget them to save time and improve your score faster, click here.

4. Not Doing Enough Questions

A question I often hear is, “Alec, should I go through Pathoma/other videos during dedicated study?” The questioner’s assumption: Pathoma can help me learn, so should I do it?

My answer to Pathoma or other videos during dedicated study? Use them sparingly!

The problem with doing lots of videos during dedicated study isn’t that videos are bad. The bigger problem is that doing videos sucks up your time to do anything else. Plus, most students don’t do the proper follow-up to ensure they’ll remember it. When is the last time you took notes on a video, then diligently reviewed them? But if you’re not doing this careful review after, you’ll forget most of it. Your dedicated study period won’t be any different.

(Note: this is why the Yousmle Online Course videos have copy-to-paste-ready flashcards. There’s no hassle or wasted time in creating your own cards. Instead, you copy and paste these cards to your Anki deck and never forget the material! You can master more in less time, and never forget it to boost your score even more effectively).

Retrospective analyses suggest the more questions you do, the higher your score. There are limitations to non-randomized, retrospective studies. However, I’d agree that QBanks should be an integral part of your studying.

Remember, the USMLEs and shelf exams require you to apply knowledge. They don’t care if you can memorize facts. Without QBank questions, you can’t use it.

Is there a wrong way to do QBank questions? Yes, and I see it all the time. Many people approach QBank questions like more information to memorize. They’re the people who have done UWorld four times. Or the ones who make huge “journals” of the facts in the question explanations. (How many people actually read these “journals” afterward is a different problem).

Instead, use the QBanks as a way to test the application of what you’ve learned. It’s one thing to know that a disease’s inheritance is autosomal recessive. It’s an entirely different thing to differentiate between autosomal and x-linked recessive conditions in a family tree.

See the most common mistakes people make with UWorld and other Qbanks here.

5. Don’t Know Question Interpretation

Do you skim vignettes, looking for “buzz words”? Do you read the last sentence first to “get a clue” of what the question is about? Have you ever studied a topic, then STILL got questions wrong about it? Or find yourself between two answers, and always seem to choose the wrong one?

If so, then you are likely struggling with question interpretation. Every sentence in a vignette has a purpose. For Step 1, few if any sentences are “distractors” Most of the time they are leading you to the correct assessment. For Step 2 CK, there is more extraneous information for you to sort through. In either case, you must know what each sentence means, and why the author put it there. That is the essence of question interpretation.

Most of us never learn to interpret vignettes correctly. We’re so used to taking tests of knowledge regurgitation that we don’t know how to use that knowledge. As such, we miss tons of straightforward questions that can make a huge difference in our scores.

How many questions are you missing because of question interpretation? For a typical NBME, I find that students miss only 50% of their questions because of a knowledge gap. In other words, 50% of the lost points have little/nothing to do with lacking understanding.

This is particularly important if your NBMEs are stuck around 220s or 230s. Often in those cases, you’re trying endlessly to cram more information into your head. However, your scores aren’t improving. My NBMEs started in the 230s. Yet, it wasn’t until I learned to interpret each sentence that I scored 250+.

It’s not possible to know every single concept/fact they could test you on the exam. (And there are diminishing returns the more we’ve mastered). If you only miss questions because you don’t know the facts, I guarantee you will be happy with your score.

To learn more about question interpretation, read my guide here.

6. Not Studying Enough

Your roommate gets a new, life-changing diagnosis. Your apartment floods. A family member is in trouble.

We know we should prioritize studying, but sometimes life is unavoidable. Unfortunately, this can have profound effects on our studying. So what can we do?

First, try to limit the number of outside commitments we make. I naively thought I could do research once a week during my dedicated studying. “Oh, it’s just once a week, on the weekends – it will be fine!” I quickly realized my error. Not only did I restrict my relaxation time, planning my experiments was stressful.

Second, if these commitments are unavoidable, consider delaying your exam. Most schools have buffers built in so that you can take extra time without enormous consequence.

Effective studying is key to improving your USMLEs in a limited time frame. However, no amount of efficiency boosts will make up for a lack of study time.

7. Burnout

Burnout affects a profound number of medical professionals. A 2016 meta-analysis looked at over 100,000 medical students across 47 countries. 27.2% of students screened positive for depression, and 11.1% reported suicidal ideation during medical school.

These rates of depression/suicidal thoughts are almost three times higher than the general population.

I’ve dealt with burnout throughout my medical career. It first started in the months leading up to Step 1 dedicated study. I sat down to take my customary practice test before our block exam and…nothing happened. I just sat there. It was like my mind went numb.

My next significant period of burnout was during the last week of dedicated study. I would sit in front of a UWorld block, and my mind would be blank. My eyes were moving across the words, but I wasn’t comprehending anything. I was irritable and got angry with those around me for trivial things.

Even worse was my indifference. At that point, I didn’t CARE what my score was.

So what did I do to overcome my burnout? I did things that made me feel human again. Over the last week, I did the bare minimum of studying. I did my old Anki cards, and that was it. No new Anki. No topics mastered. I didn’t even do any QBank questions. (To this day, I still haven’t done my UWorld “incorrects.”) Instead, I ran every day. I meditated, journaled, and had long dinners with my mom.

By the time I got to my exam, I felt much better. In fact, I had one of the calmest, even zen-like test-taking experiences of my life. I wasn’t worried. Instead, I carefully considered what every word and sentence meant. The answers were always logical, and I could quickly eliminate the wrong ones. (For more on how you can achieve this, as well, see my article on question interpretation).

So, do you think you might be feeling burned out? If so, check out this self-assessment for burn-out. I’ve found it to be helpful as a 5-minute gauge of my burn-out level.

Feeling burned out? See my article on flow/intrinsic motivation for ideas on how to be more engaged and refreshed.

Concluding Thoughts

After reading this list, you likely have a good idea of why your scores aren’t improving. You may have even had a strong suspicion before reading.

Knowledge is one thing. However, what you do next is most important. It’s not enough to read about what to do. You have to take action.

What are the top three reasons you identified for your NBMEs not improving? Write them down, and commit to changing them today!

Let us know below in the comments what struggles you’ve had in improving your NBMEs. How are you working to overcome them? What has worked? What hasn’t?

Photo by Lacie Slezak

  1. SecretCervix says:

    Dr. Alec,
    I purchased your basic package and frankly, I’m overwhelmed. I only have 2 weeks before Step 1 and I think we need a different strategy on how I can improve my QI in record time. If I had 3 months prior to the step 1 exam, I’d follow your instructions to the letter but with my circumstance, I need something significantly more streamlined. I’ve watched the videos on QI and I’m a bit frustrated with the glitches I’m experiencing. I’m not really sure what to do at this point

  2. Usmle Cram says:

    Hey Alec,

    I am having multiple problems of the ones listed above. I have been preparing for a while now, yet my scores are not improving and are far from decent. I only have about 4-5 weeks left, so not enough time for a course I believe.
    What I would like to know is, if you think your anki deck would be of any help even without the course?
    Any insight on how to proceed further would be of great help.

  3. Levi says:

    Hi Alec,

    i read your recent post and i realised i’m having the same problem of unable to interpret the questions. my NBMEs are in the low 180s. And my understanding of the concepts are poor. I am not sure of how to proceed from here. I really feel lost right now. Should i spend my time going through textbooks to strengthen my basics? I have been using your Anki decks but i am having problem with doing it regularly and keep repeating the same mistakes. Please help me. I am not sure what exactly is my weakpoint. I felt like i rushed through most of the materials .

  4. Brian Wu says:

    Great stuff! Wish I could have used your stuff more as a med student! As a current psychiatry resident, do you have specific resources for specific topics, such as psychiatry. I know we should probably create our own cards but was just curious if you have any thoughts on what would be a similar book like FA for psychiatry (I have my own opinions but would love to hear yours).

    Also our in training exams focus less on application of knowledge and more on memorization. I still think a lot can be applied to the same principles you have but wanted to ask if you had any other thoughts on preparation of ITEs/Board exams?

    Thanks! Keep up the great work.

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Want FREE Cardiology Flashcards?

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