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UWorld: Is Your Strategy Wrong? (I Scored 270 By Ignoring The Dogma)

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Virtually every medical student who has prepared for Step 1, Step 2 CK, or Step 3 has used UWorld (sometimes called “UW”).  Formerly known as “USMLE World”, it is held in near-religious reverence for its questions that match the USMLE Step exams’ two-step reasoning process, with explanations that bring medical students to tears of joy and have cured several forms of cancer.

I jest, but when I was a preclinical medical student at Stanford nervously anticipating my USMLE Step 1, I bought everything I was told.  “Everyone” knew that all you had to do to destroy Step 1 was to read First Aid five times, and do UWorld at least twice (and review your wrong answers another couple times for good measure).  Then and only then were you ready to brave the rite-of-passage exam.

So why did I ignore this advice?  And what did I do to eventually boost my score to 270?

NBME UWSA Score Graph USMLE Step 1: most of my score improvement happened before I used UWorld

Here I deconstruct several of the most common beliefs surrounding the UWorld Question Bank, and see whether they withstand rational scrutiny.  Know that as much as the “common knowledge” surrounding UWorld is opinion, this is also my opinion, based on my experiences preparing for Step 1/Step 2 CK, as well as having tutored students for the USMLE Step and Shelf exams.

NOTE: I considered sifting through any of the number of anonymous USMLE forums to find examples of this advice, but to be honest, I still get pangs of anxiety whenever I look through those forums, with all of their distress and breathless dogma.  If you are one of the admirable, brave souls who can use those without getting palpitations and find any such advice, share it in the comments and I will update this article (but I might not visit it myself =).

Claim #1: You must repeat UWorld at least twice (even if it means not doing another QBank)

This is perhaps the most common advice I heard as a medical student, and one that I ignored.  What is the basis for this common medical student belief?  The main reason given is that, because UWorld is such a fantastic resource (and it really is), that doing it MORE THAN ONCE will somehow boost your score even further.

This is one of the most common misconceptions I see among students preparing for Step 1: if something has helped you in the past, then somehow doing it infinitely more will increase your score indefinitely.

This sounds reasonable until you consider that it ignores the opportunity cost of spending weeks repeating UWorld over and over.  In other words, every single time you repeat a UWorld question, you are losing the opportunity to study a question from a different question bank, one that might help you grow your knowledge in other ways that UWorld will not.

UWorld is fantastic, but is by no means infallible.  There are definite strengths and weaknesses to UWorld, and to ignore other valuable resources is to set yourself up for potential disappointment.  For example, it is excellent at making difficult two-step reasoning questions, although tends to be weaker on more recall-type questions that are also seen on USMLE Step 1.

Verdict: Fiction, although to get the most out of any question bank, make sure to use Anki to make sure you never make the same mistake again.

“So how many times would you recommend repeating UWorld?”

UWorld questions are as close to the real thing as possible. As such, I did NOT do UWorld twice.

I considered, and still consider, UWorld questions to be as close to the real thing as possible, and as such, I do NOT recommend doing UWorld twice.  Why is this?

One of the most difficult things about the USMLE Step 1 is that you will see questions that you have never seen before, or even thought about.  My real secret to scoring 270 on Step 1 is this: knowing how to reason through questions that you’ve never seen before and arrive at the right answer differentiates people who are scoring <240 vs. 250-270.

How do you prepare well for questions you’ve never seen before?

By practicing questions that you haven’t seen before.

This might seem obvious, but I think that people mistake the fact that UWorld is as close to the real thing as possible to making the mistake that every question on their USMLE Step 1 will be exactly like a question they’ve seen on UWorld.  This is not true, although the number of students who claim that their test was nothing like First Aid/UWorld imply that the students making this mistake are numerous.

Full disclosure: I used Kaplan’s Question Bank first, then did UWorld second, for a total of 2 question banks used.  I didn’t repeat either, and didn’t even go through my incorrect questions.

Claim #2: You should begin UWorld at least a year before your exam

This advice falls under the category of “All you need is UWorld and First Aid.”  In this school of thought, the only things Step 1 will test you on are found in these two resources, and so all you need to do is to drink from their never-ending fount of knowledge as early and as much as possible to arrive at USMLE High Score Paradise.

Doing well on the USMLEs (and Step 1 in particular) involves having as much integrated, applied knowledge of the human body as possible, and knowing how to apply it to clinical scenarios.  While I agree that introducing a QBank into your studies early in your second year or even late in your first year is useful, this definitely does NOT have to be UWorld (I would even argue that this is a waste of the UWorld questions).

As I’ve stated numerous times, I scored 270 on Step 1 NOT because I had more knowledge than 99.9% of other medical students, but rather because I got really good at applying pathophysiologic principles to questions I had never seen before.  By constantly practicing my ability to apply knowledge to novel clinical scenarios, I vastly improved my Step 1 score.

The two times I had repeated wrong questions (once by accident, and once by curiosity), I found that since I was using Anki, I could remember not only what the right answer was, but also what the flaw in my reasoning had been when I first saw the question.  And while I may have improved my knowledge slightly by repeating the question, I found that I learned much less in 30 minutes of work than if I had simply done 30 minutes of the Kaplan QBank.

Verdict: Fiction, although if you plan on only completing a single QBank once, then I would recommend using UWorld

Claim #3: UWorld is the most similar to the real exam

As much as one can mimic a test that specializes in showing you questions you’ve never seen before, UWorld does the best job.  Having been a medical school tutor for years, and worked with dozens of students, I can say that the difference in quality between Kaplan and UWorld isn’t all that vast, although if I were to do only one question bank, I would still choose UWorld.

Verdict: Fact (see caveats above re: best uses)

Claim #4: The more times you repeat UWorld, the higher your NBME exams / USMLE score will be

This is an example of good advice that has gotten mangled by our over-anxious medical student minds.  Everyone likes to see a positive trend on their NBME exams, and so when we see our NBME exams going up after doing 20 blocks of UWorld questions, we think that our scores will go up an equal or greater amount if we do 20 blocks more.  This may be true to an extent, but we tend to forget the diminishing marginal returns.

As we discussed previously, I do not believe that repeating UWorld questions is good practice for seeing questions we haven’t encountered before, which will happen on your test day.  I’ve often wondered why there are so many students who take the test who come out saying that it was nothing like what they’d prepared for, and wasn’t at all like their UWorld questions, while there are others (including myself) who claim it was very similar to what they’d expected.

Why is there such a difference?  Having worked with multiple students who have failed Step 1 prior to coming to me, I believe that the difference in these two groups’ experiences stems from what they believed the test to be.  The first group often feels that the exam is simply a test of facts, facts that they will accumulate by doing UWorld questions over and over while reading through First Aid until they fall asleep with drool running down the pages.  The second group knows that they can’t possibly learn every bit of knowledge on the test, but that the point of the exam isn’t knowledge so much as your ability to apply principles.  They recognize that memorization itself is insufficient – they must learn how to apply that knowledge to interpret the test questions correctly.

The latter group sees the QBank merely as a means to an end, a practice ground to hone their reasoning skills for the day of the test, and in my experience as a USMLE tutor, this group tends to do much better.

Verdict: Fiction, at least in my experience and the experience of most of my friends/students

Claim #5: You must use UWorld in your USMLE preparations

This is a no-brainer.  I completely agree.

Verdict: Definite fact.

Claim #6: UWorld should be the last question bank you use before taking Step 1/Step 2 CK/Step 3.

Again, like many of these pieces of dogma, the answer will depend on what you believe the test to be.  If you believe it to be a test of knowledge, then doing UWorld right before your exam may or may not be as important.  However, if you believe that the USMLEs are in fact a test of your ability to apply knowledge to questions you’ve never seen before, then you will likely want to use UWorld as the final question bank before you take your test, as this is the best QBank I’ve found that mimics the real test conditions.

If it isn’t already abundantly clear, I fall in the latter camp – those that believe QBanks are a learning tool, to learn critical information as well as how to apply it to novel situations.

Verdict: Fact (depending on what you believe). 

Concluding thoughts

While I am sure there is going to be disagreement, my goal with this blog post was to challenge the dogma surrounding the use of UWorld.  While it is no doubt an extremely useful question bank, it is by no means the holy grail of USMLE Step 1 preparation as it is so often held to be.

Ultimately, your preparations and how you use these resources will depend on what you believe the test to be about, and what you believe it takes to get a high score.  As a medical student and USMLE tutor, I worked under the assumption that Step 1 wouldn’t be a receptacle for me to regurgitate UWorld/First Aid knowledge, but rather a series of carefully constructed questions that would test my ability to integrate and apply pathophysiologic principles.

You are free to disagree (and I welcome your thoughts in the comments)!  Remember that there isn’t only one way to approach using UWorld, and that there are plenty of viable, rational alternatives!

What to do next?

  1. Curious to know how I prepared for the exam?  Check out the table of contents.
  2. Worried this is only a single voice in the wild?  Check out these students’ experiences and see that there is a rational, measured approach to improve your Step 1 scores.
  3. Planning on doing more than one QBank?  Check out Kaplan’s Step 1 QBank.
  4. Know the worst mistake I see students make using First Aid for the USMLE Step 1?  Check out this article here.
  5. Interested in Step 1, Step 2CK, or COMLEX tutoring?  Check out the tutoring page here.

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What do you think?  Are you still planning to repeat UWorld twice?  Other thoughts?  Let us know in the comments!

Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored 270 on the USMLE Step 1 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.