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USMLE Step 1 207 to 241 in 4 weeks

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by Grateful Student in Yousmlers

For the USMLE Step 1 (and Step 2CK for that matter), there is a huge difference between knowing a topic, and being able to apply it to the exam itself.  Most of us went to schools that literally trained us to memorize facts – rather than understand or integrate concepts.  It’s not until we reach Step 1 that we realize just how appallingly deficient we are at using knowledge to actually make sense of clinical vignettes.  Below is one student’s description of his painful realization of just what he was lacking for Step 1, and what he did to improve his score from 207 to 241 in 4 weeks time.  For his privacy, he refers to himself as “grateful student.” – Alec

Ok – going from a 207 on my NBME to a 241 on my official USMLE Step 1 4 weeks later wasn’t as straightforward as it might sound. That said, I want to share my Step 1 journey with you and how Alec and the Anki cards helped me get the right mindset and approach in order to do well on the exam – and how you can learn from my own mistakes to boost your own studies, regardless of where you are. I’ll outline some of the lessons I learned along the way in the hope that they can help you achieve the scores you are capable of reaching.


As an IMG going to a Caribbean medical school, I dedicated a little over 5 months for Step 1 studying. I worked with Alec over the course of my study period by meeting with him every month and also participated in his Online Course live group sessions. Our one-on-one meetings would involve going over my NBME practice exams and talking through the questions I got wrong.  I was scoring in the low 220s on my NBMEs and got below 210 on two of them.

Then, I got a 207 on NBME 17 4 weeks before my real exam.

Something was not right!

So, what did I do differently over the next 4 weeks that completely changed my trajectory and led to a final score of 241 on my USMLE Step 1?

Commit 100% to question interpretation from the start!

Alec, from the very beginning, honed in on the fact that I was inconsistent in my use of his question interpretation method. I had watched his video [see sample lecture here] on using his method and understood the steps. However, I did not commit to the deliberate practice that was required to become proficient [Note: I share some of the same principles in the newsletter, for those who have signed up – go to the top of this page, or to to sign up, or you can sign up for the Online Course where I will even give you personalized feedback on 2 questions that you analyze – Alec].

Alec’s method centers on 4 principles: (1) Interpret each sentence (2) Come up with a standalone question, or a question that can be answered by itself, without knowing anything about the question stem/vignette (3) Predict the answer (4) Eliminate the wrong choices.  The goal is to eliminate “silly” mistakes – questions where you know the subject well, but yet still find yourself missing them again and again, either because you misunderstand the subtle hints in the question itself, because you don’t understand what they’re asking you, or because you’ve mistakenly convinced yourself that somehow answer “A” makes sense in a weird, twisted kind of way.

For example, the first line of a Q says “78 year-old male comes to ED with abdominal pain”. Using my old approach, I would have passively read through the first line and moved on to the next sentence. With Alec’s method, I am starting the interpretation from the first sentence. I am already thinking why would an elderly man have abdominal pain? Is it ischemic colitis? Diverticulitis? UTI? I am paying attention to the age and how it changes my set of differentials. You also start to anticipate. If you are thinking ischemic colitis, you ask yourself could he have atherosclerosis? And surprise! the question gives you 4 different risk factors for atherosclerosis 3 lines down. Steps (2) and (3) help you become more confident in your answer and not be swayed by the wrong answer choices. Lastly, step (4) seals the deal because you know why the other choices are wrong.

As Melody’s post illustrates on how she improved on her Step 1 score of 226 to a Step 2 CK score of 260, this is incredibly powerful when deliberately practiced every time you do a question. You reach a more profound understanding of the question by the time you reach the last sentence!

I didn’t force myself to use the method in a consistent manner, and as a result, even though my knowledge was improving, my ability to answer questions was not. I would fall back to my old ways of reading and analyzing questions, and as a result my NBME scores would stagnate.

I believe one reason for this was that I was hyper-focused on covering and understanding the material. In retrospect, it is natural that I spent so much time trying to learn the material and let my ability to apply it to vignettes languish; every medical school exam until Step 1 had tested straight, rote knowledge.  Don’t get me wrong, that aspect of your studying is fundamentally important but so is your ability to interpret questions, particularly Step 1.

Now back to that low NBME four weeks before my exam. When I met with Alec, he was very honest and clear in his feedback. He again emphasized what I was not doing. However, he made a suggestion for which I am very thankful for. He told me to completely dedicate my remaining time on deliberately practicing question interpretation. I listened, and accepted.

I think it was the utter disappointment which resulted from getting a low score so close to my exam that removed any resistance I had. For the next 3 weeks, I wrote out my interpretations for each question and practiced Alec’s method and I kept up with my Yousmle Anki cards. I also attended the question interpretation sessions held by Yousmle mentors as a part of the Online Course, where they would walk us through challenging questions and explain exactly what each line meant and how all the sentences fit together. They were key in demonstrating how question interpretation should be done and how effective it can be.  During the week before my exam I took NBME 18 and UWSA2 together and scored 223 and 241, respectively.

I believe this deliberate practice over the course of 3 weeks was able to bring together my knowledge in a manner that allowed me to succeed on the exam. Fast forward, I scored a 241 on the real deal. I know I am fortunate that I was able to score higher than my NBME average but I know it would not have been possible if I had not spent those 3 weeks working on question interpretation.

I have a very clear reason for sharing this aspect of my Step 1 experience: Don’t make the same mistake. Work on question interpretation from the very beginning. You might have seen some version of the following diagram. So even if you are early in your preparation, focusing on learning and understanding, make sure to deliberately practice Alec’s steps. Even if you do 5 questions– do those 5 questions using his method.

Don’t try to re-invent the wheel; improve on it instead

This one is really simple: Use the Step 1 and Pharm decks that you can get on the Yousmle website.

I was late to using Alec’s Anki decks. I would spend a lot of time trying to understand and master concepts on my own from a variety of review books. I would then create my own cards only to find the same concept already in Alec’s Step 1 deck. There were numerous times when we were going over my wrong NBME questions that Alec would point out that the underlying concept was already in his deck!

Here are some of the changes I made which allowed me to transform my use of time and ultimately spend more time on mastery and retention, and less time scouring Google for explanations and facts:

I would still work on understanding and mastering concepts on my own. Afterwards, I would search Alec’s deck for cards associated with the topic I had just mastered. This helped in a variety of ways. First, I saved time. Second, I could have a deeper understanding of the concepts in Alec’s cards because I had just spent time mastering them. Third, I could focus my time on creating cards that supplemented my knowledge and the concepts in Alec’s decks. This is what I mean by “…improve on it instead”.

One thing becomes very apparent when you start using Alec’s Anki decks. A lot of his cards focus on core concepts and key differences. This was very different from the cards I used to make. My cards were very one dimensional, they tested one fact exclusively. While it was easier to go through these, they were not very efficient in terms of understanding. For example, I would create a micro card that tested simple recall about a particular toxin. Alec’s card on the other hand would test recall of that toxin in comparison to another toxin, and how those differences led to presentation of disease. You are engaging the same content but the deeper level that Step 1 expected me to know it.

Also, the sooner you start the better. I wish I had started incorporating the decks during the second year of medical school. They are organized by subject and organ systems, and this makes it very easy to cover each system along with your classes.

Final Thoughts: Importance of having a coach

I see Alec’s role in my preparation as a coach – a coach that understands the fundamentals of the game so well that he knows precisely what you are doing wrong, and how to correct it. I worked hard and put in the effort that was required to do well but having someone who could clearly point out my deficiencies and shortcomings was absolutely invaluable.

Working with Yousmle is a commitment, both in terms of time and finances. That commitment is an investment in myself. I could have easily spent that time and money in taking a review course but I am very glad I didn’t.  Review courses have a one size fits all approach. With Yousmle, I could identify my particular weaknesses to improve my individual weaknesses and get real time feedback that allowed me to spend my time in a much more effective way

Lastly, working with Alec over the course of my preparation led to a very pleasant change. Studying medicine became enjoyable! Since Alec emphasizes understanding and mastering concepts, the material became more logical. It was not just about retaining facts but about having a more complete understanding.

Don’t confuse enjoyable with easier. Alec’s method will ask more of you. For example, rather than simply being able to state the different types of anemias covered in First Aid you need to be able to explain how their different presentations are linked to their pathology. You must be able to logically reason out the labs that the question gives you. Alec will ask what labs do you expect to see even before you read further on in the question. Again, this asks more of you because it goes beyond just “covering FA”. In my experience, this was well worth it because studying became logical and there was a deep sense of satisfaction when 5 different concepts come together and you say “Ahhh I get it now!”

Wish you all the best in your studies.


A grateful student

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.