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How Your Step 1 Prep Influences the Rest of Your Career

You think that it's ok to forget everything after your exams...but is it?

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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.

by Alec Palmerton, MD in Plan

Most medical students begin medical school with high ideals and even higher ambitions. Very quickly, however, our best intentions are stymied by a seemingly endless list of facts and figures to memorize. All too often, students find themselves struggling just to stay afloat. The ones who figure out a way to do well in their classes often get there by simply memorizing – then forgetting – a jumble of words they don’t understand.  These same students are setting themselves up for disappointment on a USMLE Step 1 that will test them to apply and integrate that information in clinical vignettes.

There is a better way, one that will set you up for success not only for your USMLE Step 1, but also for your clerkships, Step 2, and even residency. You can read my Step 1 study plan here.

This article will address the myth that all hard work is created equally. Two stories will demonstrate how your decisions and actions not only affect your Step 1 preparations, but the rest of medical school, residency, and your medical career.

The Myth: Hard Work is All You Need

When I started medical school, I thought that all I needed to do was work hard. I had this vague notion that medical students pushed themselves to the limit every day, stayed up late in the library, and measured their success by how tired they were the next day.

When I arrived at Stanford University School of Medicine, I felt deep down that success would be a battle of attrition; only the students that pushed themselves hard enough would be able to succeed.

I was dead wrong.  To illustrate this point, I will share two stories of medical students to demonstrate the cumulative, long-term effects of your actions today.  Each of these students made very different choices during their first years of medical school, which set very different trajectories through their USMLE Step 1, clerkships, and residency.

Dina Do-Everything: Poor Prioritization of Mastery/Retention → Cramming → Lack of Mastery + Forgetting → Weak Foundation

Let’s start with Dina Do-Everything (a friend whose details are modified to protect privacy). Dina went to a top-3 Ivy League undergrad, and did extremely well, and was accepted into Harvard Medical School.  She was outgoing, extremely hard-working, and did a great number of things well.  Her gift was that whatever she saw others do, she could figure out a way to do it better through a combination of hard work and will-power.

In her first year of medical school, she threw herself into every task of medical school.  Every quiz, test, project, problem-based learning discussion, and presentation – Dina figured out a way to fit in time to do these things.  She saw her classmates begin to find research projects, and so found a research project that occupied some of her nights and weekends.

She began to reach the limits of what she could fit into her schedule.  However she figured out that by spending the first part of a block on her research and other commitments, she could defer her heavy studying for the week before her exam.  She never really did an all-nighter, so convinced herself that this would be ok.  Plus, she continued to do well in her classes, and her classmates were always amazed as how many details she could recall before she took her tests.

She had a vague sense that she was “cramming” and not able to truly master much of the information, but was comforted by the fact her scores on her med school exams were quite good, and few of the rest of her Harvard classmates seemed to be going much beyond memorization.

Preparation for the USMLE Step 1 was when Dina began to realize that something might be wrong.  Her first NBME Practice Exam was WELL below what she had been hoping, which was puzzling given how well she had done in her classes.  Because of her limited time-frame, she willed herself to do UWorld twice, and to get through First Aid multiple times, each time hoping she learned more than she was forgetting.  She could see that she knew many of the things she was tested on at one point, however had forgotten them, and didn’t have enough time to go back and re-learn them properly.  Her ultimate Step 1 score was good (a 245), although not what she had hoped for, particularly given how well she had done on her MCAT and how much she had sacrificed her personal life in her pursuit of doing everything well.

What she found, though, was that her struggles were only beginning.

Just like she had to re-learn much of the information for Step 1 she had crammed for her medical school exams, on her shelf exams she found she had to re-learn huge amounts as well.  Her internal medicine shelf exam (standardized exams most students have to take after each rotation) was so much of a repeat of Step 1 material that she ended up going back to her First Aid book.  Her surgery shelf, because of the overlap with internal medicine, was much of the same, as was Step 2, of which more than half was internal medicine.

Step 3?  A continuation of the theme of cramming and having the information quickly leak out of her head.

Now, in her residency in anesthesiology at one of the top programs in the country, her cram and purge rhythm continues to challenge her – she had to meet with the program director recently, because her latest annual “In-Training Exam” put her at risk of failing.  She’s so worried that instead of taking her last vacation to rest like she needs, she spent most of it bouncing between coffee shops, studying for her next In-Training Exam.

Her experiences are, unfortunately, all too common.  Because they are so common, we come to accept these as just “normal medical student experiences,” that “everyone goes through.”  I remember being told the same thing.  However, as you will see, my journey was considerably different.

The Road Less Traveled: Slow Growth of an Ever-Expanding Sphere of Mastery

Knowledge is like a sphere. As the radius grows, the more of the unknown the surface contacts; the more you know, the more you realize you don’t know. However, as the radius grows, the rate of knowledge volume growth increases exponentially.

– My Grandfather

A wise person said once, “Urgent things shout, important things whisper.  Listen to the whispers.”  This was used in the context of prioritizing important over urgent tasks, and can be used in all aspects of one’s life.

Early after I entered Stanford Medical School, I had been encouraged by my advisor to cultivate a calm ear, one that would listen to the whispers, so I could focus on important tasks, and that would ignore the many shouting, seemingly urgent things that constantly cropped up.  When my classmates at Stanford started immediately looking for research projects, I could feel the pangs of guilt, as they were already working hard for the promise of publications, research stipends, and connections in their (supposedly) desired residency fields. In addition, my friends quickly started to do every extracurricular I could imagine, and some I hadn’t even thought of. They were taking leadership positions in various clubs, organizing classes, directing the free clinics, learning phlebotomy and other practical skills, or doing media internships with major broadcast organizations.

Me?  My sole focus was to find a sustainable, daily “rhythm.”  Every day, I made it my goal to simply master the things that we had learned in class, turn them into Anki (spaced repetition) cards, and to make sure I did all of my old cards.  Every single day, my goal was to master a modest number of new topics, and make sure I never forgot them or anything else I’d learned previously.

To read my guide on Anki for medical students, click here.

My fundamental goal was to slowly grow an ever-expanding foundation of things that I had mastered.

While I had to work hard to overcome my feelings of inadequacy, and to fight the feeling that I wasn’t doing “enough,” I believed deep down that my own professional satisfaction, my ability to help patients, as well as my exam scores, would directly depend on my ability to master and retain an ever-growing body of knowledge.

I believe that was right.

Early Results from Mastery/Retention Similar to Cramming

In the beginning, my results were indistinguishable from many of my classmates. I scored well in my exams, but so did others. Even though I felt that I understood the information at a deeper level, it didn’t necessarily show on the exams, since most of the exams would test us on minute details that were memorized from PowerPoint slides, rather than testing our ability to integrate and apply the knowledge. In subsequent blocks, I would still do my old cards from previous blocks, even though that information wouldn’t be tested on my next midterm examinations.  This made learning the new information harder in many ways, since not only was I trying to master new things but also to hold onto all of the old things I’d mastered. I pushed on, however, since I could still hear the whispers that my goal was larger, that I wanted to remember all of the important information that I’d mastered, not just do well on each of the exams.

This was a whisper that I was particularly grateful for, one that has laid the foundation for not only success on standardized examinations, including Step 1, but also allowed me to have enough balance in my life to have a family (and this website) during a busy residency.

As time went on, many of the subjects that I learned in the previous months were repeating themselves. By the third time we’d covered diuretics, I barely had to study, since I’d already learned it twice, first in our cardiovascular block, and second during a pharmacology section.

Because my goal was to master whatever topic was learned that day, and to make sure I never forgot what I mastered, as Step 1 approached, I had very few gaps in my knowledge.  This allowed me to focus all of my energy on mastering what few topics I hadn’t mastered the first time around.

Spaced Repetition: Retain More and More Information for Less and Less Time

Because of the incredible power of spaced repetition, during my dedicated study period, I only spent a modest amount of time every day to remember the things that I’ve mastered during my first two years of medical school. As all my friends were frantically cramming paper flashcards filled with the names, mechanisms, uses, and adverse effects of hundreds of drugs, I simply did the reviews that were due each day, being able to recall in several hours of work each day, all of the important information that I learned in my first two years of medical school.

Additionally, because I could recall so much information with comparatively little effort, I threw all of my effort into mastering the art of question interpretation, figuring out what each sentence was trying to tell me, and developing an approach to tackle any question on the exam in a systematic way that limited “silly” mistakes – questions whose topics I had mastered, but that I still got wrong because of careless errors.

My score of 270 on the USMLE Step 1 wasn’t my goal, but rather a byproduct of mastering, retaining, and learning how to integrate and apply a vast and growing body of knowledge during my first two years.

Since my goal was to retain and apply what I learned in medical school and residency in the care of patients, I continued with my cards, even in subjects like biochemistry, genetics, or immunology, that would be unlikely to show up on another standardized exam again. In part, this was a desire to be able to continue to use that information, and in part, it was because it didn’t take that much time to remember that information.

By the time I entered clerkships, it took roughly an hour of reviewing my old cards every day to retain all of the information that I learned in my first two years of medical school. As you might imagine, this was an incredible help for my Shelf exams. By doing a modest number of questions, but keeping on top of all of the old information that I’d learned, and using the skills that I developed of question interpretation during my Step 1 studying, I honored every third-year shelf exam.

The benefits of gradually growing my mastery of topics over time have only expanded during residency.  While a resident, after going through a single question bank, and making cards on it, and retaining all of the information that I learned for medical school, I only study about 45 minutes a day of my old cards – 45 minutes a day to remember everything I had mastered in all of medical school and residency!  With that modest investment in ongoing studying, I scored in the top 10% of all of my In-Training Examinations, and even got a special letter from the national Board organization in anesthesiology congratulating me on my performance on the basic examination.

Even more, although I made nearly 20,000 cards during medical school, because of the extensive knowledge I had acquired during medical school, I have made fewer than 2000 cards through all of residency – so much has repeated itself that there is that much less to learn.

Concluding Thoughts

What’s the point of my story? I’m not trying to brag. Rather, I want to show you that you have a choice in how it is that you learn the information.

How you choose to use your time, and whether you listen to the whispers, or let the shouting, urgent tasks of your medical training overwhelm you, will have long reaching implications, both for your clinical training, and your ability to carve out a personal life for yourself.

The ever-present cram and purge cycle is all too common in medicine and can certainly get you through. Medical students are smart and hard-working, which is a potent combination, even when faced with poor studying techniques. However, when that same intelligence and industriousness is turned towards gradually building a strong foundation over a long period of time, the difference can be immense.

Your Next Step Can Change Your Life

I don’t make bold pronouncements lightly, but what you choose to do next has the potential to change the trajectory of your preparations, your career, and your life overall.  The fact that I can remember essentially everything I mastered in medical school and residency by only studying 30-45 minutes a day has allowed me an immense amount of extra time to spend time with my wife and daughter, to travel the world, and to pursue a large number of outside projects that most residents wouldn’t even be able to dream about.

So what is the next step?

You must develop an effective daily rhythm.  Master a new amount of information every day, and make sure that you never forget it by doing your old cards.  Every day.  Only once you’ve established an effective daily rhythm of mastery of new things + retention of all of the old will you be able to gradually grow a strong, durable foundation.

If you’re not sure where to start, or would like to accelerate that process, check out the Yousmle Step 1 Cards.  Here, you can find pre-made cards on all major subjects that will teach you how to master some of the most difficult subjects.  Not only will you save time on learning the information, but you will also save immense amounts of time by not having to make the cards yourself!

What do you think?  If you continue on your current path, where will it lead?

  1. Sebastian Brito Orama says:

    m doing the step 1 deck, and i cannot understand why is it that the levels of ACE are increased in the pulmonary endothelium with heart failure.

    1. Yousmle says:

      Hey Sebastian, thanks for your question. Remember, in heart failure, the idea is that you have a decrease in your cardiac output (either because of a decrease in contractility, AKA heart failure with reduced ejection fraction; and/or because of a decrease in preload, AKA heart failure with preserved ejection fraction), which leads to a decrease in your blood pressure. Your body misinterprets the signal, via the baroreceptors, as you having not enough blood volume, and as such, will increase both the sympathetic tone, as well as the renin angiotensin aldosterone system. This is why there’s an increase in ACE, as well as why inhibitors of RAAS as well as beta-blockers are still the major things that actually improve mortality in patients with heart failure.

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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.