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Beyond UFAP: Why a List of Resources Isn’t a Good Step 1 Strategy

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by Alec Palmerton, MD in Plan, Question Interpretation
Being Different

UFAP is some of the most common advice you’ll hear for Step 1 prep. UFAP (or a new variant, “UFAP + Sketchy”) stands for UWorld, First Aid, and Pathoma. (The “Sketchy” in the new version refers to Sketchy Micro). On every message board, people breathlessly extoll its virtues. Want a great Step 1 score? All you need is UFAP, obviously! Need to score a top residency? UFAP it is!

When I started as a med student, I followed this gospel blindly. As a first year, what did I know? The second-year students were saying all you needed was UWorld + First Aid. That’s it! Everyone repeated this so much that it became ingrained in our heads.

Over time, though, I started to question the wisdom of this advice. If it were that simple, why wasn’t everyone scoring 260? And what would happen if I didn’t use UFAP? (Spoiler alert: I scored in the 260s on Step 1 NBMEs before using anything more than First Aid. My final score was 270.)

In this article, I will lay out:

  • What is UFAP, and why it is such common advice
  • What are the pros of UFAP
  • Why “just do UFAP” is stupid advice
  • What you should do instead if you want high USMLE scores

Table of Contents

Conventional Wisdom Is Right…Except For When It’s Not

Conventional wisdom can protect us. We follow tradition, what has worked in the past. If it’s worked for others, it must be right!

Many things that we follow are helpful. Children learn to wash their hands. We learn how to say, “please” and “thank you.” Many (most?) conventions help protect us.

Except for when following the crowd causes more harm than good. “Conventional wisdom” is right until the exact opposite is found.

Learning to wash our hands? Not more than 200 years ago, washing hands wasn’t a common practice. The 1800s “conventional wisdom” held that imbalance of the four humors caused disease. In Hungary, Dr. Ignaz Semmelweis developed an early version of the germ theory. He told obstetricians to wash their hands. Did they immediately ditch convention and thank him for his efforts? No! They called him crazy, fired him, and even locked him up in an insane asylum.

Everyone went along following conventional wisdom, causing massive maternal infections.

Being Different

Being different, even if you’re right, isn’t always easy

UFAP: Why Is It Such Common Advice?

I have two theories for why UFAP has become such ubiquitous advice. The first is our fault for thinking too narrowly. The second is the fault of medical culture, for promoting the idea of invincibility.

Let me explain.

Theory #1: We Ask the Wrong Questions by Focusing on Resources

Imagine you’re talking to someone who scored 270 on Step 1. You’re sitting down with them at a coffee shop. You’re super excited to learn the secrets to a top Step 1 score.

What’s the first question you ask?

If you answered, “What resources did you use?” you’re in the majority. How do I know? Because that is the #1 question I get all the time when people find out I scored 270 on Step 1.

Ask around, and enough people will tell you they used similar resources. Come up with a (semi-)clever acronym, and you’ve got yourself a UFAP!

While it’s undeniable that many high-scorers have used UWorld, First Aid, and Pathoma, it’s still the wrong question. However, it’s undeniable that many high-scorers have used UWorld, First Aid, and Pathoma.

Theory #2: Medical Students Want to Look Like a Boss

My second theory involves the culture of invincibility that permeates medicine. You know what I mean. Everyone wants to look cool and pretend like everything comes easily. No one wants to admit spending all weekend locked in the library.

At Stanford, it even has its own acronym, “SDS” or “Stanford Duck Syndrome.” (Ducks look calm on the surface, but are paddling furiously underneath the water). Classic SDS: a friend asks you how you seem to know all the answers. You answer, “I dunno, maybe it’s all the television I watched last week?” (True story: one of my Stanford friends loved to talk up how much television he watched. Yet somehow he matched in one of the top surgery programs in the country. “TV.” Right.)

So what do you say when someone asks you how you scored so high on Step 1? Do you tell them:

A) I sacrificed my relationships, my sanity, even occasional personal hygiene. I studied so much I had a severe vitamin D deficiency, despite living in sunny California. (Another true story, btw, this time for me. The vitamin D deficiency, not the personal hygiene…).
B) Just do UFAP!

If you haven’t witnessed the I-Just-Did-UFAP-Like-Everyone-Else shrug, you haven’t been paying attention. I still remember one of my Stanford classmates who was famous for this behavior. First, he’d casually mention he was so surprised at how high his Step 1 score was. This was immediately followed by a humble-brag that he’s only used UWorld and First Aid.

Who knows, maybe Mr. Humble Brag really did *only* do UFAP. But I doubt it. However, the rest of us will never know. In the quest to make ourselves look amazing, some (many?) med students under-share. And as a consequence, we get platitudes like “UFAP, I guess?” for how people scored so high.

UFAP isn’t all bad. It is a reasonable place to start. You definitely need a QBank, and UWorld is fantastic. First Aid is a great way to find an outline of the information you need. And Pathoma provides reasonable explanations for a lot of pathologies.

Why “Just Do UFAP” Is Stupid Advice

The problem, however, is that a list of resources isn’t a coherent plan. It isn’t even a hazy strategy.

If you asked me how to bake a cake, and I handed you some flour, sugar, and eggs, could you do it? No! A list of ingredients is only part of the puzzle. You need to know how to use them.

Could you make a cake with only the ingredients? Then why would you expect a high Step 1 score from only a list of resources?

Could you make a cake with only the ingredients? Then why would you expect a high Step 1 score from only a list of resources?

Let me put it another way. Let’s say I asked someone who scored a 260 on Step 1 what resources they used. Then I asked the same question to someone who scored 160. If I gave you the two lists, could you guess who scored higher?

No! Why? Because the lists would be indistinguishable. A list of resources isn’t a strategy.

What’s missing? HOW you use them.

Another problem with the UFAP approach is the assumption behind it. When people say, “do UFAP,” what they mean is, “all you need is UFAP for a high score.”

Did you catch the assumption behind this statement? Implicit is the belief that there is a list of resources and if you just use those resources you will get a high score. It’s the same assumption behind questions like, “Is Kaplan enough to get a 240?” Or “are UWorld + the Yousmle cards enough if I want to break a 250?”

These resources provide information, but information and rote learning are not sufficient.

However, the USMLEs are different from high school exams. In high school, questions focused more on rote learning. Instead, the USMLEs focus on our ability to apply knowledge. (More on this later).

Repeat after me. A list of resources isn’t an actual strategy.

Beyond UFAP: What Should You Do Instead?

If a list of 3 resources isn’t a strategy, then what should you do? Here are 3 recommendations that can help you improve your score at any stage.

1. Master the material, use spaced repetition never to forget it

“It’s the wizard, not the wand.” One of my anesthesia attendings during residency loved to say this.

What did he mean? Everyone has the same tools. Instead, what makes excellent doctors is what’s between your ears.

Resources are no different. Most students will use very similar resources. However, there is a vast range of outcomes. Instead, your focus should be on HOW you use those resources.

The most important thing is to learn how to integrate and apply the material. Unlike med school exams, the USMLEs don’t care if you can memorize lists of random information. In fact, they actively discourage cramming by using clinical vignettes.

Take the time to master the material. It will pay enormous dividends in higher scores and better clinical performance. You can read more about how to ensure high yield studying here.

2. Use a high-quality question bank. Don’t repeat questions.

QBanks are a critical part of your preparations. But how are you supposed to use them?

Proponents of UFAP often advocate repeating UWorld multiple times. But why? Often the assumption is that UWorld is closest to the real exam. As such, they claim you should try and glean as much knowledge from UWorld as possible. (Again, the emphasis is almost always on facts, not how to use them).

I followed a different approach. I didn’t think of UWorld as a source of knowledge. Instead, I used it as a way to apply what I’d already learned. Remember, the NBME’s primary focus is to see if you can apply material not memorize it. Vignettes test whether you know how to use clinical principles.

I advocate using high-quality QBanks once each. Why? Because your actual test will have many items you’ve never seen before. Repeating the same questions may lull you into a false sense of security. How will you feel if you’ve been doing familiar questions for weeks, then see all new items on your test? Panic. Confusion.

Ever heard people claim “my test was NOTHING like UWorld”? In my experience, those people are the ones who repeated UWorld multiple times. Instead, train yourself for the unknown by always using new, unused questions.

To read more recommendations on UWorld, read this article.

3. Learn how to interpret questions

Years ago, Step 1 was filled with “buzzwords.” You could skim a passage for “Gray Baby,” not read anything else, and get the question right.

Those days are long gone. Instead of regurgitating First Aid, now you have to interpret each question’s nuances. Why is the patient with arm weakness presenting with high blood pressure? What’s the significance of smoking history in a woman presenting with syncope? Is the family history significant or just extraneous noise?

In short, you have to know how to interpret questions correctly. This skill is essential. Want an estimate of how many items you miss because of poor interpretation? Go through an old UWorld block or NBME. Tally the number of questions you lost because you didn’t know a particular fact. These are the number of “knowledge” questions you missed. The remainder is questions you likely missed from poor interpretation.

Miss points because you don’t know what the question is asking? Interpretation problem. Lower scores because you were thinking “stroke” instead of “seizure”? Interpretation again!

Want to learn how to stop missing questions you should be getting right? Read more about question interpretation here.

Concluding Thoughts

Let’s be very clear. UFAP can be excellent resources. I recommend many of them. However, a list of resources doesn’t substitute for an actual plan.

So what should you do next time you talk to a high scorer? Be sure to ask them about their approach, not just the resources they used.

What do you think of UFAP? Let us know in the comments!

Photo by Nick Fewings

1 Comment
  1. Jonathan Alverio Rivera says:

    Hi Alec!

    I was wondering if it’s worth buying the access to the program now, or waiting to take pathology. Surely you will say that now it is better because it is better to prepare with time like any sport. but could you explain how I can benefit from the course if I do not understand anything about pharm or physio, etc?

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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.