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The Thoughtful Step 1 Pass-Fail Study Plan

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by Alec Palmerton, MD in Uncategorized

You may be wondering, “now that Step 1 is pass-fail, do I need to study very hard for it?” We’ll assume you want to 1) get a top Step 2 CK score to get into your top residency choice, and 2) be an excellent physician. But how does Step 1 studying fit into this?

What would you do if you had a biology final that was pass-fail in college but a physics final that was graded? You’d do the minimum to pass the biology test and spend most of your time on the physics exam!

But what if your mid-term physics exam was pass-fail, but your final was worth your entire grade? Would you slack, pass your mid-term, and wait until the last minute and cram for your final? Of course not!

Instead, you’d prepare diligently from the beginning. Your mid-term may not “count” in the strictest sense. However, the work you did for it will form the basis for your final grade.

Step 1 and Step 2 CK are like the pass-fail midterm and high stakes graded final. Do well on Step 1, and acing Step 2 CK becomes that much easier. (Although even if you’re disappointed with Step 1, there is still plenty of time to course-correct).

In this article, we’ll discuss how to approach Step 1 now that it is pass-fail. Specifically, we will discuss:

  • Why and how to study for Step 1 now that it is pass-fail,
  • The best predictors of your Step 2 CK score,
  • The psychological reasons that preparing for Step 2 CK is more challenging than Step 1, and
  • Much more

Goal: Get a High Step 2 CK Score

Residency programs get too many applications and have too little time to review them. For years, program directors have relied on USMLE scores as screens for applications. Residency programs reject roughly 50% of applications each year based on automated screens, many of them based on USMLE scores.

Now that Step 1 is pass-fail, Step 2 CK will take on added significance. Already, many program directors are planning to shift the emphasis towards Step 2 CK. Surveys of PDs all suggest that Step 2 CK will become the new Step 1:

  • In a survey of dermatology PDs, 86.0% (49/57) indicated they would increase their emphasis on Step 2 CK.
  • 78.2% (43/55) of these PDs also reported they would begin requiring Step 2 CK for all applicants.
  • In one survey of internal medicine PDs, 87.8% said Step 2 CK scores would be more important
  • 96.9% of these orthopedic surgery PDs said Step 2 CK would become more important
Overnight Success Takes Years

So, everyone knows that Step 2 CK will be more important for residency applications. But what does a stressed-out, overworked med student do about it? What is the right plan to get a high Step 2 CK score?

To paraphrase Jeff Bezos: overnight success takes years.

First, start by imagining your ideal Step 2 CK test day. You’re calm, collected. Every question makes sense. You can mind-read the test writer, filtering out the “noise” meant to distract you. You are confident in your answers. When your score comes back in a few weeks, you’re pleasantly surprised at how well you did.

Now imagine what you did every day leading up to that. Did you:

  • Cram, hoping to get by through memorization of random PowerPoint slides and their details or did you
  • Methodically master the concepts underlying medicine and learn how to apply them?

It doesn’t take a genius to know that the second approach will be the winner. But what is simple isn’t always easy – and learning things well is easier said than done.

What Does Mastery Look Like?

Mastery means that you understand concepts and can apply them to understand facts. Here are some simple examples from the Yousmle Online Course, where we teach students how to master concepts, not memorize details.

Have you memorized facts like these?

  • Estrogen is available in a transdermal patch
  • Testosterone has an intracellular receptor
  • Fluoroquinolones have a high oral bioavailability and good lung penetration
  • Lidocaine doesn’t work well in abscesses

Would you believe me if there was a straightforward concept that could help you explain all these seemingly unrelated facts…and thousands more?

That concept? “Likes dissolve likes.” Specifically, the things that can diffuse across lipid membranes are:

  • Small,
  • Lipophilic, and
  • Uncharged

Are estrogen, testosterone, fluoroquinolones, and lidocaine all small, uncharged, and lipophilic? Yes! And as such, are you surprised that they all can cross lipid membranes – the blood-brain barrier, the lungs, the GI tract, and even the skin? Of course not!

Now, you may be wondering, “but Dr. Palmerton, how could I possibly know if something is small, uncharged, and lipophilic?” You don’t have to! The magic of concepts is that if you know a fact – like, say, that lidocaine can give you seizures –you can infer it is most likely small, uncharged, and lipophilic. Why? Because if lidocaine can cause convulsions, it must cross the lipid membrane of the blood-brain barrier. And if it can cross one lipid membrane, it must meet our three criteria AND be able to cross other membranes. (The high H+ content of abscesses can make lidocaine positively charged, hampering its effects in infected areas).

Mastering and Applying Concepts Makes Learning Faster/More Enjoyable and Leads to Higher Scores

With a single concept, you can now predict thousands of facts:

  • Volumes of distribution,
  • Modes of drug administration (IV vs. transdermal vs. oral),
  • Which drugs cross the placenta,
  • Which drugs cross the blood-brain barrier,
  • Why do certain hormones have intracellular receptors, and
  • Much, much more

Most people believe that mastery is essential but that it is too hard. Yes, it is challenging to master and apply the concepts underlying medicine. However, while understanding can be challenging, memorization is even tougher. Imagine memorizing every one of the above facts – then multiply that by everything you must know in medicine.

Want a faster, more comprehensive path to mastering the critical concepts of medicine? Join the Yousmle Online Course to learn medicine the right way – concepts, not details.

Feeling Overwhelmed Makes Us Reactive, Not Proactive

We got into med school because we were proactive, not reactive. We worked from the beginning rather than waiting until the last minute, especially when the stakes were high.

In medical school, we know that being proactive is better. However, medical training makes reactivity – not proactivity – the name of the game. The “firehose” of information overwhelms med students—many struggle to keep up and end up cramming last-minute. Then, exhausted by staying up late into the night, they are exhausted by the start of the next block.

In contrast, being proactive involves mastering – not memorizing – the clinically relevant information that shows up on Step 1 and Step 2 CK. Understanding and applying this information is critical for being at your best on Step 2 CK.

Your Step 1 Score May Matter More Than You Think

So, to recap, getting a high Step 2 CK score is critical for residency applications. Likewise, mastery – not memorization – is crucial for high USMLEs. However, because it is such a distant goal, it is hard to do that consistently.

Wouldn’t it be great if there were milestones along the way to a high Step 2 CK score? Rather than slaving away for three years and hoping for the best, wouldn’t you like to predict your Step 2 CK score months/years before taking it?

Researchers have been asking this question for years. Research suggests that there is a high correlation between Step 1 and Step 2 CK scores. One of the best predictors of Step 2 CK has been Step 1 scores.

In this paper, researchers tried to create an equation to predict your Step 2 CK score. Their findings help us figure out the best way to study for Step 1 to get a high Step 2 CK score:

PredictorStep 2 CK score correlation (r)
Average subject exam score for IM, surgery, and pediatrics shelf exams0.81
Average subject exam score for IM, surgery, and Ob-Gyn shelf exams0.80
Step 1 score0.75
Preclinical mean exam score0.54

You’ll notice that the best predictor of Step 2 CK scores was:

  • Step 1
  • A combination of three shelf exam scores: internal medicine + surgery + pediatrics/Ob-Gyn

Note that preclinical med school grades were a weak predictor of Step 2 CK score. Why might that be? As discussed previously, med school exams often focus on memorizing minutiae and practicing by taking prior years’ exams. The USMLEs, by contrast, focus on the application of essential concepts – not memorization of isolated facts.

Do you find yourself in the understandable – and regrettable – position of cramming without understanding? If so, this Step 2 CK prediction research suggests that you may want to re-evaluate your approach. Instead, make sure that you master the material – not memorize it – so you’ll be able to use it on Step 2 CK.

Concluding Thoughts

Are you worried about standing out to residency programs now that Step 1 will be pass-fail? Do you cringe every time you read another program director survey that anyone that doesn’t go to a prestigious medical school will be disadvantaged? Are you worried about how to study for such a high-stakes test that might be years away?

If so, you are not alone. It is stressful to feel like you are the guinea pig for a system-wide experiment. It’s even worse when there is no established playbook on what to do.

That said, with change comes opportunity. Having a high Step 2 CK score doesn’t have to be a three-year blind prayer. Instead, focus on the things that you can do – today! – that multiply your chances of success:

  • Master concepts – don’t memorize details
  • Be proactive, not reactive
  • Use Step 1 and your shelf exams as benchmarks for your future Step 2 CK performance

Follow these steps, and you can claim the overnight success that takes years.

Want guidance on mastering the concepts that underly medicine? Like the idea of weekly check-ins to help you course-correct? Do you like the idea of not having to take any notes…but still master hundreds of diseases? Then, sign up for a free consultation and learn how the Yousmle Online Course can help you master – not memorize – for impressive scores and a more meaningful career.

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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.