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USMLE Step 1 Score of 270: Is Memorization Enough?

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by Alec Palmerton, MD in Beginners

As someone with years of tutoring experience, who has worked one-on-one with dozens of students, and has had led classrooms totaling thousands more, I have had a lot of time to think about just what makes for a successful student, particularly one who will score exceptionally well on their USMLE Step 1 and other standardized medical school exam.  What I have found is that the ingredients for a successful medical student are NOT what you might traditionally think: intelligence, ability to memorize, or even work ethic.  Rather, the most radically different thing about people that do exceptionally well is this:

High scorers on the USMLE Step 1 doggedly, persistently move beyond rote memorization to seek out explanations.

Let me very clear about this: there is a persistent, incorrect perception that the best medical students are simply more efficient automatons who can cram more useless facts into their heads for the exam, then regurgitate it for an exam before promptly forgetting it all.  While that may have allowed students to slide by exams in high school and college, and while it may have even allowed them to pass or even excel at their exams during their preclinical clerkships, the memorizing mentality is the exact OPPOSITE of what it takes to succeed on the USMLE Step 1 exam.

From writers of the USMLE exam, to people who have themselves scored in the 260s+ on Step 1, to students I have worked with personally, the consensus is irrefutable: while there are certainly things you have to memorize, the most successful students are those who understand the material, and can apply it to novel situations.  Let me give you an example of a classic Step 1 type scenario, for a topic that is notorious for people to think (incorrectly) that all they are supposed to do is memorize huge volumes of information: biochemistry.

An 5 year old patient is brought in by his parents after suffering a seizure.  His past medical history is remarkable for suffering somnolence after extended periods of fasting or illness.  You check his blood, which is remarkable for hypoglycemia and very high amounts of very long chain fatty acids, but normal levels of medium chain fatty acids.  What compound is most likely elevated in his blood?

A. Acetyl-CoA

B. Ammonia

C. Pyruvate

D. Urea

The answer would be ammonia, since in this case of VLCAD (very long chain fatty acyl CoA dehydrogenase) deficiency, you would lack the requisite ATP to allow for the urea cycle to run, which would lead to a build-up of ammonia in the blood. To the student who simply memorizes for the exam, this is yet another example of a fact in a long list of facts that must be memorized, while for the person who has searched for their own explanations of why someone would present with VLCAD deficiency with these symptoms (can’t metabolize very long chain fatty acids, so will be more dependent on gluconeogenesis/glycogenolysis for energy during starvation/illness, leading to lower blood sugar levels), this is yet another application of a “story” they have already created in their head.

The question that inevitably arises is, “I KNOW I should learn deeper explanations, but my school/textbook/syllabus/lectures don’t explain it!  HOW do I find these sorts of explanations and develop this sort of understanding?”  Here are some tips for how to maximize your yield of searching for/creating explanations.

  1. Find the right resources – the easiest way to find explanations if to find resources that emphasize understanding over memorization.  Go to the resources page.
  2. As an exercise, when you consider a fact you’ve just learned, challenge yourself to apply it.  Say to yourself, “and this is why…”  It may sound silly, but this saying something like, “the urea cycle requires the equivalent of 2 ATP…and this is why…” can help re-focus your attention to the ultimate goal.
  3. Make a running list of questions you have, that you regularly refer back to.  You will be surprised at the number of things you can explain after studying a block/subject for even for several days.  Even if you can’t explain it, formulating a question helps to clarify what you’ve learned.
  4. Seek out your professor after classes, or write them an e-mail.  During the 10 minutes between classes, I would often go up to professors to clarify something I didn’t understand in lecture.  If your professor is busy, ask of your friends if it made sense to them.
  5. Sign up for the YOUSMLE newsletter, where I regularly share both my best Anki questions, as well as explanations for the most difficult and high-yield Step 1 topics.

What do you think?  Please share your experiences with the rest of the YOUSMLE community by leaving a comment below.

  1. disqus_XgPyFsLmT6 says:

    Thanks Alec. Wasn’t sure where to post this question. 1) I love the sompayrac immuno book. Are there any others that you read before starting the lectures on that topic, even if they weren’t as awesome? 2) is there anything else besides anki (usmle and class material) that you did that helped prepare for third yr , at any point during your preclinical years? 3) do you have advice on how to learn symptoms, how do you know which are the major symptoms that are important to know vs the rest, or do you learn all? Thanks u rock

    1. Yousmle says:

      Thanks for the message! These are fantastic questions.

      1) I LOVE the immuno book, probably the best book I read in medical school. Because it worked so well to get a big-picture understanding of immunology first before taking the class, I tried for other books. There is another book in the series that is not quite as good, but still helpful at I never was able to finish it, though, since things got too busy, but what I read was quite useful.

      2) I didn’t really do anything special to prepare for 3rd year/clerkships. I will say, though, having gone through clerkships, that being able to follow clinical scenarios in question stems for Step 1 questions is surprisingly applicable to clerkships. I hope to publish some articles on more clinically-oriented stuff later, which I would hope would be done by the time you enter clerkships =)

      3) I found it really hard to know WHAT the specific symptoms were for each disease, and what the key ones were. It is surprisingly difficult to find good pre-clinical resources for this, and lecturers are not always the most helpful, either (unfortunately). Probably the best resource I found was using Goljan Pathology, whose book I prefer to the Pathoma book (

      Thanks for the comments, and the fantastic questions. I can’t wait to hear more about your journey through medical school!

      Take care,

      1. disqus_XgPyFsLmT6 says:

        Thanks a ton! You are too awesome. I hope you do post new articles cause i will read all of em.

        1. Yousmle says:

          Haha, thank you so much for your kind words!  As it turns out, residency is not easy, but I will do my best to post articles semi-regularly.  I remember all too well what it was like to be a medical student, and if I can help anyone to avoid some of the mistakes I and countless others have made, it will have been worth it =)

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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.