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I Scored 258 on Step 1 in 6 Weeks. Here’s How You Can Do Better.

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by Alec Palmerton, MD in Yousmlers
USMLE Question Types

Scoring 250+ on Step 1 is a huge challenge. It’s even harder when you have a limited dedicated study and want to match into a super competitive specialty. When someone does it, it’s always impressive.

In this article, Daniel reflects on his journey that will take him to a top dermatology residency in the midwest. (Disclaimer: I tutored Daniel from early in his first year of medical school, and he was part of the Yousmle Online Course.) He gives his advice on not only how to score well on Step 1, but also how it fits in your overall medical training. Unlike other top scorers, he also shares his missteps along the way, so you can build on his success.

Here is Daniel:

I scored 258 on Step 1, despite having less dedicated time than most students. (We had only about 1.5 months). Delaying wasn’t an option. Plus, my goal was always to match into dermatology. (I ultimately matched into a top dermatology residency, without taking extra time). Thus, to get a high Step 1 score, I needed to be efficient, both before and during dedicated studying.

Here are some pieces of practical advice for preparing and taking Step 1. Take it with a grain of salt and take away the bits and pieces that resonate with you.

1. Step 1 = Excellent Clerkship Preparation

Many students told me that Step 1 was nothing like clerkships. They told me none of the things I’d supposedly memorize would matter in clinical practice.

I couldn’t disagree more with those who say Step 1 is unrelated to clinical practice. In fact, the keys to success for Step 1 and clerkships are the same:

  1. Learn things well the first time (i.e., not cramming)
  2. Be curious about everything you learn, even if you don’t think it’s high yield

These are the comments that residents and attendings put in positive clerkship evals. They’re the same things that will help you score high on shelf exams.

Develop good habits now, and they’ll stick with you for the rest of your medical education.

Step 1 Clerkship Preparation

Preparing well for Step 1 sets you up for clerkship success.

2. Teaching Others Improves Mastery

Most high scorers I know agree: you have to master the material. Memorization doesn’t work on the USMLE.

To master material efficiently, find one or two people who you can teach concepts to and who can teach you. If you can teach something, you will have mastered it.

3. QBanks: Best (And Bad) Practices

Everyone uses QBanks, but not everyone does it well. Here are my recommendations.

Use Anki With Your QBanks

First off, have Anki open as you review QBank questions. Make simple cards with the answer to the fact that you didn’t know in the item. A lot of people make the entire question into an Anki card, but this isn’t very helpful – it takes too long to review. (Same thing goes for full second passes of a QBank – this is useless.)

Save these Anki cards to review during your dedicated study period. You will have forgotten the answer to most of these questions by then, a few months after the fact.

Start With Kaplan the Winter Break Before Boards

Start Kaplan at the beginning of winter break before boards. Do 40 questions a day on weekdays and 80 a day on weekends. Don’t miss days. You should finish around mid-February.

Sometimes, this is around the time that your school may administer their NBME exam. That’s good. Kaplan will teach you many of the little distinctions that are tough. (E.g., brachial plexus injuries, biochemistry. Basically, anything that has a table in First Aid).

(To read The Best Winter Break Step 1 Study Plan, click here).

Do UWorld After Kaplan, and Continue with Anki

Once you’re done with Kaplan, start UWorld with the same rhythm. You will finish by the beginning or early into dedicated study period. At that point, start reviewing your Anki cards and give First Aid a read over once.

(To read UWorld: Is Your Strategy Wrong? (I Scored 270 By Ignoring The Dogma), click here).

Don’t Use USMLERx

When I finished Kaplan and UWorld, I started doing QMax/USMLERx. USMLERx was horrible.

Scoring 250+ on Step 1 involves mastery of the material. Useful questions force you to apply the knowledge you’ve learned. Instead, USMLERx made me feel as if the key to answering questions was memorizing details. (As it did with many friends and me).

My take: Rx’s questions disincentivize good interpretation.

USMLERx May Have Hurt My Score

USMLERx wasn’t helpful. In fact, it may have actually hurt my score. Let me explain.

I completed the Kaplan and UWorld QBanks and saw my NBMEs rise consistently. At this point, I felt good on question interpretation. However, I felt a little short of details, so I decided to try USMLE Rx for a few weeks. I did the majority of the medium and hard questions and during this time saw my NBME score flatten out and then drop.


My scores went down when I used USMLE-Rx. They went up when I stopped.

Perplexed, I went over my recent NBMEs with Alec. Many of the questions I was missing were due to misinterpretation. In other words, I knew the facts well, yet was still getting items wrong.

Our hypothesis? USMLE Rx overemphasized facts and caused question interpretation atrophy.

I quit Rx. Instead, I worked exclusively on question interpretation for the last few weeks. I saw my NBME scores return back to normal. My final score was higher than any previous NBME I’d taken.

4. First Aid: Use Early, Often

There are many things I wish I had done differently in my preparation. One is that I wish I’d reviewed the material in First Aid for a unit while I was studying that in class.

There are lots of topics that you may never learn in class but that you have to know for Boards. (E.g., renal tubular acidosis for me). It’s way easier to learn something complex when you’re immersed in that organ system. In contrast, learning later during your dedicated study period is much more difficult.

My advice: read through the First Aid section for that unit by the end of each school unit. At the least, you should have a decent understanding of the material within it.

First Aid: A Quick “Pass”?

I took the last weekend right before the test and read through First Aid. I’m not sure if this helped on any specific questions. However, I think it helped me make a few more connections that I had missed during my studying.

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

5. NBMEs: Use a “Bonus” Self-Assessment as Baseline, Familiarity

The NBME often retires a self-assessment every year in March. In other words, the oldest NBME will no longer be accessible after around late March. If you haven’t taken it yet, you won’t be able to.

If you want an “extra” NBME, take the oldest one right before starting back after winter break. This will give you a rough sense of where you are and see what the test is like.

If your school offers an NBME, you’ll be able to take up to 8 NBMEs during your studying. (The “Extra” + 6 others + your school NBME).

Also, take the last two NBMEs together, back to back, about a week before your test. It’ll be tough but will give you a sense of what the timing will be like for the test.

(To read NBME Self Assessments: Ultimate Guide for the USMLEs and Shelf Exams, click here).

6. Test Day: Relax, You’ve Been Here Before

Roughly 40-50% are simple, straightforward questions. Probably not as easy as some of the “Really?” questions on NBMEs, but not much head-scratching is required. Remember, they’re not trying to trick you. Sometimes the answer really is that obvious.

About 30% are more complicated. You will have seen variations of these before in things like Kaplan or UWorld. For example, some of the questions with 12 answer choices with ↑/↓/⟷ in 3-4 columns.

Very few depend on you truly random knowledge that does not appear in First Aid or any common resource. (Around 3% – 5-10 questions total). For example, I had a question about a random gene mutation which only appears (very briefly) in Robbins.

In other words, the “WTF” questions are few and far between. You shouldn’t stress about them; chances are no one else has seen them either.

The Most Important Questions Force You To Synthesize Knowledge

The best, most interesting questions are the remaining 15-20%. The ones that make you synthesize knowledge to understand an essential clinical point.

Just like Alec’s cards, they force you to integrate medical knowledge. These integration-type questions also make QBanks like UWorld so valuable.

These questions made me so glad I followed Alec’s advice. He told me to try to truly understand concepts and go beyond just First Aid and Sketchy Micro.

As much as you can, question everything. How does the natural function of Vitamin C help explain why we can use it for methemoglobinemia? Which GERD medication would be contraindicated in someone with osteoporosis? Which osteoporosis medication would be contraindicated in someone with GERD? Why can ondansetron potentiate serotonin syndrome even though it’s a serotonin antagonist?

These are the kinds of questions that Alec taught me to seek to understand.

(To read The Secret to Scoring 250/260+ You Can Learn Right Now: Question Interpretation, click here).

USMLE Question Types

Questioning everything helps when you need to synthesize knowledge on Step 1.

7. My Most Important Advice for Preparation

Learn the material well the first time (in class), and be curious about everything that you learn. This is the highest yield of any of the advice I can give.

When you sit down and take Step 1, you can’t be processing these questions for the very first time. You can’t even be thinking about them for the second time. To do your best, you will want to have seen these questions 3 or 4 times before. That means that you’ve been processing this material for as long as possible.

Master as much material as possible early on in medical school and commit it to long-term memory. It’s tempting to cram for your tests and kick the can down the road. However, don’t expect to relearn everything during your dedicated study period.

Concluding Thoughts

Right before I pushed the start button on Step 1, I had a mild panic attack. I was finally going to see the questions I had spent the last 2 years anticipating. But then I thought about the fact that I had spent 2 years preparing, and that I was as ready as ever.

I’ll tell you what Alec told me right before I took the test:

When you get there on test day, don’t change a thing from what you’ve already done the last 2 years.

And in the wise words of Goljan, just play the odds.

What do you think? What are you happy about with your Step 1 preparations? What would you change? Let us know in the comments!

Photos by Mathew SchwartzMartin Brosy

  1. Ameer says:

    Hi Alec,
    I see that you told Danial to stop using USMLERx and to go back and focus on question interpretation. Are you implying that there are step 1 resources that focus on how to interpret questions, and if so what are those resources. Or were you implying he should go back and look at Qbanks that he already did?

  2. olushola20 says:

    Hi Alec,
    I recently finished reading FA and watching USMLERx Express videos. I am currently doing questions. I wanted to know if you think the way I am studying is effective? I plan on going over FA and Uw at least 2 times.

  3. Jp says:

    Hi Alec,

    I recently bought your step 1 and pharmaco deck because my score right now is 220 and I would like to reach 260 by October.

    I set up 30 FC per day for step 1 and 30 for pharmacology, which already helped a lot.

    Unfortunately it takes me almost all day.
    Am I using your product correctly? Do you have any advice to speed up the process?


  4. Anon 144000 says:

    Hi Alec,

    Initially, I planned to take STEP 1 in 25 days with an NBME of 130. I’m embarrassed that I intended to take the exam with such a low score expecting a miracle. There were external factors (and still are) that made me afraid to delay. Thankfully, I came to my senses and extended my eligibility period.

    I’m not able to officially sign up and confirm a date yet but I intend to take it sometime in August. In other words, I gave myself 10 weeks (72 days) to reach my goal score of a 225-230. I would like a higher score obviously but not sure if it’s feasible.

    I intend to start your program in a couple days, after I finish all the related videos. I didn’t buy the Kaplan Q-bank but have only been using UWorld since that’s what the school provided for us. I also went with the UFAP system since I started studying (technically) in January.


    1.) Considering my situation, should I buy Kaplan and do those or should I just stick with UWorld? (I barely went over the whole thing once. Out of the total of 2,759 questions, I’ve only used 860 questions. I also have many old exams that I haven’t reviewed. I almost feel as if I should do all of the questions over again.)

    2.) Now that I extended my time frame to an extra 2.5 months, how many MINIMUM hours of studying should I do per day?

    Thank you so much for taking the time to answer my questions! I appreciate the time and effort you dedicate to helping students.

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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.