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Study for Classes or Step 1? Here’s How to Rock Both.

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by Alec Palmerton, MD in Plan
USMLE Stress

You may not realize it, but you face a critical choice. Specifically, how will you study for your classes and Step 1? It’s a decision that has far-reaching consequences.

Residency programs reject roughly 50% of applicants via simple screens. The #1 reason? Low USMLE scores. Programs consistently rate Step 1 as the #1 factor they use in offering interviews.

If that makes you nervous, you’re not alone. If you’re like most students, you can barely keep on top of your classwork. How could you possibly add Step 1 studying to the list? It’s impossible!

However, it’s not impossible to study for Step 1 during your preclinical courses. In fact, you can do better on your med school tests AND improve your future Step 1 score.

In this article, you will learn:

  • The two most common pieces of “advice” to preclinical students, and why they’re wrong
  • The reasons why med school teaching is awful
  • Why med school tests set you up for failure on the USMLE
  • How you can do well on preclinical exams AND Step 1, and
  • Much more

The Most Common Advice You’ll Hear (And Why It’s Wrong)

Everyone has a different opinion about what preclinical students should be doing.

“Just study First Aid! Classes are worthless!”

“No, you need to focus only on your class material! You’ll forget all the Step 1 material by the time if you start now, anyway.”

You may feel overwhelmed by the often conflicting advice. First, let’s discuss the pros + cons of the most common preclinical Step 1 advice. Then we’ll discuss how to excel in your classes while setting yourself up for fantastic Step 1 scores.

Strategy #1 (NOT Recommended): Focus on Classes Now; Boards Material Later

Most likely, someone has told you, “focus on your classes now. You’ll forget all the Boards material you study now anyway.”

Your med school likely endorses this strategy, either explicitly or implicitly. Why? Because they believe what they teach you matters!

The default is to focus on your classes, so it’s natural advice to follow. You know Step 1 is essential. But you’re so focused on survival, you can’t do anything else. “How can I study for Step 1 if I can’t even keep on top of my class material?”

Few People Intend to Study Only for Classes…But That’s What They Do

You likely didn’t PLAN to focus only on your classes. At one point, you had vague but ambitious plans to do UWorld questions after class or on weekends. You would sneak in a few Pathoma videos. Few students intend to ignore Step 1 studying until the end! But you already feel so behind, where do you have time for UFAP?

You know you’re in a short-term trap. You know that Step 1 is looming. Maybe you read a random page in First Aid or two. Or watched a few Pathoma videos. (Who cares that you forget them the next day!). You’re struggling to keep your head above water, and you don’t know what else to do.

USMLE Stress

Classes can be overwhelming, and make you want to curl up in a ball.

The 3 Problems of Focusing Solely on Class Material

What’s the problem with focusing only on your class material, and ignoring Step 1 material? Three reasons:

1) Classes Underemphasize/Miss Lots of Relevant Step 1 Material

The obvious problem with the class-only approach: classes miss high-yield Step 1 material. It’s a common med student complaint. “Why are they teaching us X and not Y? Everyone knows it’s not high-yield!”

To an extent, it’s unavoidable that schools will “miss” some things. The USMLEs can test anything.

2) Professors Are Encouraged to Suck a Teaching

This is a bold claim, so what do I mean? More specifically, the medical education system incentivizes poor teaching.

Why do med schools systemically teach poorly? The short answer is:

  1. Professors are paid/promoted for clinical work and research. Because they’re not paid to teach, they’re incentivized to minimize their lecture prep.
  2. Because professors are not paid to teach, lots of doctors teach one-off lectures. Because each professor may be responsible for only one talk, there is no continuity. (And again, a strong disincentive to create integration across classes).

The incentive for poor teaching leads us to the third downside to the class-only approach. Class exams reinforce wrong Step 1 learning.

3) Focusing on Class Exams Sets You Up for Step 1 Disappointment

So why does focusing on school exams lead to weak Step 1 results? Remember, professors have a strong disincentive to teach well. They’re not bad teachers – the system encourages them to make teaching the lowest priority.

When constructing exams, professors write the least time-consuming questions. These questions are unlikely to be the high-quality vignettes found in Step 1. Instead, they focus on minutiae.

The problem with minutiae-heavy exams? It encourages you to cram and memorize, exactly the wrong approach to high Step 1 scores.

(To read What 250+ on Step 1 or Step 2 CK Means, and How to Do It, click here).

It’s a paradox of med school tests. The more you focus on acing your med school exams, the worse you’ll understand the material. Focus on class, and you’ll miss relevant Step 1 material. Plus, you won’t learn it well.

This leads us to the second most common preclinical strategy.

Strategy #2 (NOT Recommended): Ignore Your Classes Completely, and Focus Solely on Boards Prep Material

Step 1 is critical for residency applications. So vital that it’s often residency programs’ #1 criterion for interview decisions. Your preclinical classes? Not so much. Preclinical grades don’t even rank on the list of things PDs care about.

This leads to the second-most common preclinical Step 1 strategy. Ignore your classes and focus on Boards-prep material from Day 1. Your class scores may not be very high. However, by focusing on things like UFAP, you likely will pass your exams.

The Problems with Ignoring Your Classes and Focusing on Step 1 from Day 1

On the surface, it makes sense. Why focus on poorly-taught material when Step 1 matters so much for your residency future?

However, there are issues with the Step 1-only approach.

1) Step 1 Can Test Anything, Including Class Material

If you want a 250+ on Step 1, you will need to know more than UFAP. Why? Because Step 1 can and will test anything. Besides, the USMLE test-writers understand what’s in well-known Boards-review resources. (What, you think they haven’t seen First Aid?)

While it’s impossible to know everything on Step 1, mastering more material helps. Focusing only on class material ignores a lot of Boards-relevant material.

2) Class Material May Teach You Clinically Relevant Material

As noted above, med students complain about the lack of Boards-relevant class material. Schools’ typical response is to say, “well, we won’t teach to the test.”

Let’s set aside the pros/cons of this debate. I will note, however, that Step 1 may not emphasize relevant clinical material. An obvious example is ECGs. ECGs are very important for clinical practice. Yet, they’re very underrepresented on Step 1. If you only focused on Step 1 material, you wouldn’t know how to read an ECG when you enter wards.

If your response is to say that your school sucks at teaching how to read an ECG…you wouldn’t be wrong. However, classes allow you to educate yourself, even if it won’t show up on Step 1.

3) You Might Fail Your Classes

Even if you are in a pass-fail system, you still need to pass. Ignoring your class material leaves you at risk of failing your classes.

4) It’s Isolating to Study by Yourself

The final reason you may not want to ignore class material is it’s isolating. While the “team-learning” approach is overdone, studying by yourself every day is lonely.

Strategy #3 (The Sensible Strategy): Master the Boards-Relevant Class Material + Things with a Logical Basis

As discussed, going all-in on classes, or ignoring them, both have serious downsides. Going all-in on courses sets you up for panic attacks during your dedicated study. Studying Boards material from the beginning may lower your score ceiling.

So if you shouldn’t be 100% in on either class or Boards, what should you do? The approach I advocate helps you excel in classes and raises your Step 1 score ceiling. The strategy?

Master Boards-relevant material and things with a logical basis from class

But how exactly can you study for classes while still mastering Boards-relevant material?

What to Do for Every Class

The problem with class isn’t that it teaches nothing relevant. It’s that the relevant content is buried in tedium, with no signposts of what is/isn’t necessary.

The material covered in class may look like this:

  • Boards-relevant material
  • Personal anecdotes
  • Tedium – facts without a logical basis/things you’d have to memorize
  • Things only a specialist would need to know
  • Descriptions of their research on exotic yeast
  • Interesting, logical content

This is why classes are so overwhelming. They say med school is like drinking from a firehose. The problem: only a part of the firehose will be relevant to Boards/your future practice.

The bigger problem: med school doesn’t highlight the important stuff.

Instead, for higher Boards scores AND better class grades, focus only on:

  • Boards-relevant material (supplemented with related First Aid content)
  • Interesting, logical material

How to Master Boards-Relevant Class Material and Supplement with First Aid

Classes cover tons of Boards-relevant material. The problem, however, is professors rarely tell you what is/is not high-yield. As such, you have to figure it out on your own.

But how do you know what is Boards-relevant? Use First Aid as a first-pass approximation.

Let’s say you have a lecture on the thyroid. The First Aid section will contain something like this:

First Aid

Source: First Aid for the USMLE Step 1 2018

Your goal by the end of the lecture is to understand everything in First Aid about thyroid hormone. The professor will cover a lot of it; use it to supplement the bare-bones facts of First Aid.

For example, one of the things you need to know is that thyroid hormone is made from tyrosine. You also need to know its receptor is in the nucleus – not extracellular.

You could memorize these things, like any number of resources. Or, you could make sense of it. As in, tyrosine is a nonpolar amino acid. Nonpolar substances generally cross the nonpolar cell membrane. As such, it makes sense that a hormone produced from tyrosine would have an intranuclear receptor.

Some of these things will be covered in class, while others won’t. (You can also use the Yousmle Anki Cards or Online Course to master this information faster).

But what about the information not covered in class? You’re still responsible for it. For the remainder, make sure you’ve mastered it, too, and have made Anki cards.

(To read The Worst Mistake Students Make with First Aid for the USMLE Step 1, click here)

(To read Anki for Medical School: FAQ for the USMLE Steps, Shelf Exams, and Clerkships, click here)

Learn Other Things with a Logical Basis

You may be wondering why you should go to class if all you’re going to focus on is the First Aid material. Why not skip class altogether, and do UFAP in your room?

This is a relevant concern. However, it ignores a trove of useful information you can get from class. Specifically, interesting insights you can learn from experts.

“But my professors just tell us bad jokes and stories about when they were med students in the dark ages.”

Ok, ok. I get it, there are (lots of) irrelevant details your classes may focus on. However, there is still plenty of useful things that can grow your pool of valuable, applicable knowledge. Here is a collection of useful facts my Stanford professors gave:

  • Virtually every cancer-causing virus is a DNA – rather than RNA – virus
  • Alcohol causes fasting hypoglycemia because it shuts down gluconeogenesis
  • Von Gierke causes gout because of an increased synthesis (and breakdown) of purines

These were often given in an offhanded fashion. But when you dug further, you’d find a logical, clear explanation for why. And by understanding why my ability to apply knowledge skyrocketed.

Ultimately, your Step 1 score will depend on how much you can apply knowledge to test items. When you cut through the chaff, classes offer powerful applicable understanding.

Why It’s Critical to Master – Not Memorize – For Top Boards Scores

Why is it essential to master the material, rather than cram? After all, many of your friends are cramming buzzwords or memorizing Zanki. As we discussed, even your school’s exams likely encourage memorization rather than understanding.

So why is it so essential to understand the material rather than memorize it?

In short, understanding is critical to answering Step 1 questions. (Let alone be a good doctor).

The NBME, writers of the USMLEs, publish the rules given to question-writers. In these rules, they are obvious. They are testing the application of concepts, NOT memorization of facts.

Here are some excerpts:

“Each item should assess application of knowledge, not recall of an isolated fact.”

“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.”

Forget Buzzwords – USMLE Questions Force You to Analyze

But what about the “buzzwords” you’ve been hearing about?

Decades ago, Step 1 was a very different exam. Questions were shorter and included many more “buzzword” type answers. Things like “gray baby” for chloramphenicol toxicity. Or “worst headache of my life” for subarachnoid hemorrhage. Resources like First Aid catered to this, like its “Rapid Recall” for optimum cramming.

Gone are the days that you can skim for buzzwords and expect to get a question correct. Again, you don’t have to take my word for it. Just look at one of the sample questions released by the NBME. (I chose the first question, at random, to avoid cherry-picking).

Source: Step 1 Sample Test Questions, 2019

What do you notice? No buzzwords! Instead, lots of analysis, including labs, vitals, physical exam, and history.

The Key: Master Material, Make Anki Cards, and Keep Up with Class!

Mastering each class’s Boards-relevant/logical information is simple, but not easy. It relies on diligence and keeping up with your class material.

(To read Step 1 Study Schedule for 250+ and Top Preclinical Grades, click here)

But What About Classes? Aren’t Class Exams Still All About Memorization?

We’ve discussed how mastering material is critical for Step 1 success. However, how does mastering material affect performance on memorization-heavy school exams?

Understanding material helps you with memorization-heavy tests, as well! Think back to the example I gave earlier about thyroid hormone. Where is its receptor located?

If you took the time to understand the explanation, you probably remember the answer. (It’s intracellular because the nonpolar, tyrosine-based molecule can cross the nonpolar cell membrane).

I experienced this happy side-effect while a student at Stanford. Even though I ignored large swaths of lecture material, I still scored in the top 10% of almost every exam. Why? Because I had mastered enough of the other content to make up for the little bits of tedium I had ignored.

We’ve Discussed What You Should Do From Now On. What About Old Material?

Another concern you may have is what to do with old material. A new Online Course student saw his UWorld block scores go from 20 to 70% in the month after joining the Course. He said he was happy but sad.

Sad that his scores jumped by more than 50% in 30 days? Yes. Because as a second-year, he didn’t know how to review the material from his first year.

The short answer: save old material for breaks and dedicated study.

Why? Because it’s hard enough to keep on top of new material from class. To add on something else will only cause you to do mediocre at both.

Here’s an example of how to cover old material during breaks and dedicated study.

  • Old material (learned previously, but not well)
  • Biochemistry
  • Statistics
  • Genetics
  • Immunology
  • Microbiology
  • Embryology
  • Cardiology

Material you’ve yet to learn:

  • Pulmonology
  • Nephrology
  • Neurology
  • Etc.

As long as you keep on top of new material, you will have time to cover the old. When? During winter break, you could cover 1-2 of the old topics. If you have a spring break, you might cover another. By the time you get to dedicated study, you could learn the remainder.

Your pre-dedicated study goal is to minimize how much you need to master during dedicated. Don’t try to cover everything.

Why You Shouldn’t Try to Cover Old Material During Your Classes

You’re a hard-worker, I get it. You may be thinking you can push yourself and learn new material AND old material. Here’s why that’s a mistake.

Giving yourself too little time to learn something will force you to cut corners. Instead of understanding it, the temptation to cram/memorize will be overwhelming. If you don’t learn a topic well, you’ll just have to re-learn it again later. The worst studying is studying you have to repeat.

Instead, do today’s work today. And save the old material for later.

Further Reading

Concluding Thoughts

A favorite story of mine goes something like this:

An apprentice (A) visits a master swordsman (MS).

  • Apprentice: I’d like to become a master swordsman.
  • Master swordsman: Great, it’ll take you 10 years.
  • A: What?? 10 years?? I’ve only got 5 years – you’ll have to teach me in 5 years.
  • MS: ok, now it’ll take 15 years.
  • A: (apoplectic) 15 years?!?! You just said 10!
  • MS: Yes, but you’re in a rush. It will take you longer.

This story illustrates the importance of not rushing. There are numerous reasons why rushing makes you less efficient. One of the biggest reasons: by rushing, you have to re-do your work.

A favorite phrase of a former PI of mine was, “slow is fast.”

Remember, the best studying is the learning you don’t have to repeat. Set a goal of mastering as much material as you can every day, and you’re well on your way to Step 1 success.

Photo by Matthew Henry

  1. Hermilio Carvalho says:

    Hah, love that story! The one I’ve heard goes a bit more into detail.

    A young, clean-faced warrior comes to a master who has been teaching swordsmanship for 27 years. Not only is the master famous for defeating great opponents, he has also produced the brightest pupils of his age.

    The young man comes up to the master and asks: “Master, I want to become a great swordsman. How long would it take?”

    The master thought for a bit, slowly scratching his long, white beard. He answered: “10 years.”

    The young man’s courageous expression fell. This would be too long for him! He asked again: “What if I trained here every day?”

    The master raised his eyebrows, and conceded: “5 years, then.”

    The young man smiled, hopeful. “What if I trained here, every day and every night?”

    The master frowned, and shrugged. “15 years.”

    “What?” The young man answered, surprised. “I would train a lot more!”

    “Yes.” The master finalized. “But rushing takes longer.”

  2. Prachi Patel says:

    Hello alec, thanks for this post. I wanted to ask that if I but step 1 deck would it work in Android anki?
    I am not sure about all the features associated with anki and hence I want to make sure before buying.

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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.