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How Much Memorization Is Needed for Step 1 and Step 2 CK

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by Alec Palmerton, MD in Uncategorized

“All you need to do is do UWorld and memorize First Aid.” To many, this is the standard advice for Step 1 and, to an extent, Step 2 CK. Yes, there are variations – the (in)famous UFAP comes to mind – but the general idea is the same. There is a fixed amount of information that you need to know. Once you’ve learned it, you’ll do OK – or at least pass.

But how much of the memorization hype is true? Or rather, how much of this is the product of confirmation bias and silent evidence? In other words, if everyone follows this advice – but only the successful ones stick around to tell us about it – what proof is there that we need to memorize for Step 1 and Step 2 CK? More importantly, even if memorization WORKS, is it the BEST and most time-efficient approach?

In this article, we will discuss:

  • Why memorization is so prevalent in medical school,
  • How cramming feels so much faster…but is much slower,
  • Why our schools still set us up for USMLE disappointment – despite the best efforts of many intelligent, dedicated administrators,
  • What you should do instead to cover more, faster, and with better results, and
  • Much more,

Why Do People Memorize for Step 1 and Step 2 CK

No one enjoys memorizing things. This hatred of memorization is particularly pronounced among those of us who choose a career in medical school. Many of us could have chosen any number of other paths. Instead, we decided to sacrifice many of our prime years because we often:

  • Love to learn,
  • Are fascinated by the body, and
  • Have a genuine desire to help others

Then how did we get into such a negative spiral of memorization? Often, people in medical training resign themselves to memorizing because:

  • Schools focus on memorization – especially for their tests
  • Everyone else is doing it
  • We need to memorize some facts
  • Cramming allows you to “see” more information faster, and
  • They don’t think they have an alternative
  • The USMLEs used to be a lot more fact-/memorization-heavy
Schools Focus on Memorization – Especially for their Tests

If you’re a medical student, you’ve probably wondered why so many lectures suck. I know I did. Yes, there are beautiful exceptions – professors who go out of their way to make learning approachable to the beginner. However, these incredible individuals are the exception rather than the rule.

What you may not realize, though, is that there are lots of caring administrators at your same school who see the problem but are largely powerless to do anything about it.

Surprised? I know I was. However, in speaking with various people in authoritative posts within medical schools across the country, a consistent theme has emerged. They recognize our training of medical students is outdated. We focus on teaching facts – WHAT to think – rather than HOW to think. Even the most motivated lecturers lack the proper training or incentives to be good instructors.

The result? A system that encourages fact-cramming rather than the mastery and application of concepts.

Nowhere is this memorization-heavy system apparent than in test questions. Under the best of circumstances, teachers hate writing tests. Add to that burden a busy clinical schedule and/or research duties, and the idea of spending hours crafting thoughtful questions flies out the window.

Instead, professors will do the easy thing: quiz you on a list of facts. Ostensibly, testing minutiae “keeps you on your toes.” In practice, though, it sends a dangerous and counterproductive message to students that all they must do is memorize the details of the PowerPoints, and they will do fine.

We Need to Memorize Some Facts

In the defense of lecturers, we do need to memorize SOME things. The more we learn, the more we see the limits of our knowledge. And in medicine, we’ve learned a lot – and thus can see the number of things we can’t (yet) explain.

Care to explain the signs and symptoms of lysosomal storage diseases? Is there a rhyme or reason to the portions of the brachial plexus?

Until a brilliant scientist or physician can help us, we will always need to memorize some things. As we’ve discussed, however, just because we need to memorize SOME things doesn’t mean that memorization should become our DEFAULT.

Everyone Else Is Doing It

Memorization is so typical that even laypeople I talk to tell me something like, “oh, you went to med school? You must have had to memorize a lot!”

It is scary to go against the crowd. More so, when we see so many people doing something, it’s hard not to think that we should do the same thing.

Crammers “See” More Information Faster

Another reason that people memorize is that it FEELS faster. We need to “make up for lost time”; who has time to understand why something happens? The only way to go over 20 pages of First Aid in a day is to skim/cram it. You can’t dedicate much if any, time to developing depth of mastery.

As you might have guessed, however, while memorization may FEEL faster, it is much slower in the long run. As we’ve discussed previously, the most unhurried approach is the one that requires you to repeat and re-learn things.

Any time anyone mentions “multiple runs through First Aid,” run. For more on why the slow and steady approach is faster, read this.

The USMLEs Used to Be a Lot More Fact-/Memorization-Heavy

Like med school exams, the USMLEs used to have more memorization. Glancing through First Aid, you will still see this legacy in the many buzzwords that used to be the clues necessary to get questions right on Step 1. “Gray baby,” or “macrophages like crumpled tissue paper,” were the keys to get some items correct.

This focus on memorization has changed, however. The NBME has wised up. Rather than test the rote memorization of facts, the USMLE question-writers now want you to apply essential concepts. They specifically state in their rule book that they give test-writers NOT to assess random facts.

Here are two quotes from the USMLE test-writers on the importance of the application of concepts:

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

“Each item should focus on an important concept or testing point.”

– “Chapter 5: Basic Rules for Writing One-Best-Answer Items.” Constructing Written Test Questions For the Basic and Clinical Sciences.

Crammers Don’t Think They Have an Alternative

As we mentioned above, one of the primary reasons students resort to memorizing is that we haven’t given them an alternative. Not only do our lecturers focus on the rote retention of facts, but so does MOST of medical training. Boards prep material is usually no better.

Little time is given to explain WHY something is. Even less effort is made to help students understand HOW to think about things.

Memorization is Miserable, Slower, and Inefficient

Memorization may feel faster. However, as we discussed, it is slower in the long run. Plus, given the USMLEs focus on mastery and application of essential concepts, memorization is unlikely to lead to high scores.

As we mentioned before, because the adverse effects of memorizing aren’t apparent until much later, we can continue on this path for some time. We will pass – and even excel – on tests that focus on rote learning in med school. When we get to our dedicated studying, we will feel good because we can fly through page after page in First Aid, even if we don’t understand anything. It won’t hit us until later when our practice tests stagnate. Then the panic sets in.

The Alternative to Memorization: Mastery/Application of Concepts

But what is the alternative?

  • The mastery and application of concepts
  • Developing a framework in which we can put the details

Think about microcytic anemias. Most of the time, you will be given a list of the causes of microcytic anemia. There will be lots of time devoted to memorizing tables of lab values (MCV < 80, RDW, etc.).

However, a thoughtful lecturer would be able to help give a framework for thinking about microcytic anemias – or other anemias generally.

Consider: anemia is insufficient red blood cell mass/hemoglobin. Red blood cells are like giant balloons filled with hemoglobin – if there is less hemoglobin, they will be small (microcytic). Anemia with small RBCs is microcytic anemia.

Now, all we have to do is figure out what hemoglobin is made out of, and we can have a framework for thinking about microcytic anemia. Hemoglobin is composed of a globin (protein) chain, heme (a porphyrin ring), and iron. Is it any surprise, then, that microcytic anemia – where there is too little hemoglobin per RBC – is due to a deficiency in:

  • Globin chains (thalassemias),
  • Heme (porphyrias) and/or
  • Iron (iron-deficiency)

Med students memorize because we haven’t shown them a better way.

Concluding Thoughts

For medical trainees, “sacrifice” is an expected part of the experience. We have come to expect that we must endure long nights of cramming facts and buzzwords. And how could we expect differently? The lay public, our peers, and even our professors encourage us to memorize rather than master the underlying concepts.

But what if we didn’t have to memorize so much? What if there were a better way?

As you can see in the anemia example above, there are better ways to learn medicine. Rather than cramming/memorizing, you can learn things deeper, faster, and with better results with a bit of extra effort.

We know, though, that everyone’s situation is different. You may lack the time, experience, or confidence to improve your approach. Even worse, after everything you’ve been through, you may feel discouraged – or even hopeless – wondering if things could be better.

We would love to help you. Schedule a free consultation so we can learn about your unique circumstances. You have dedicated your life to helping others – the least we can do is listen and do our best to lighten your load.

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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.