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

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by Alec Palmerton, MD in Plan
UWorld Strategy Wrong

Virtually everyone who’s taken 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. Its questions match the USMLE Step exams’ two-step reasoning process. Its explanations bring medical students to tears of joy. It’s even rumored to have cured several forms of cancer.

I jest. But when I was a Stanford preclinical student stressing over 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?

Table of Contents

Does the Dogma Make Any Sense?

Here I deconstruct several of the most common beliefs surrounding the UWorld Question Bank. Do they withstand rational scrutiny?

The “common knowledge” surrounding UWorld is an opinion. This is also my opinion from preparing for Step 1/Step 2 CK. It also comes from 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. However, med student forums still give me pangs of anxiety, with all of their distress and breathless dogma. If you can brave forums without getting palpitations, share it in the comments and I will update this article. (But I might not visit it myself =).


Claim #1: Repeat UWorld At Least Twice. (Even At the Expense of Another QBank).

This is perhaps the most common advice I heard as a medical student. I ignored it.

Why does everyone tell you to repeat UWorld? It’s simple: UWorld is a fantastic resource (it really is). Therefore, doing it more than once will somehow boost your score even further.

If a little of something is good, then more must be better, right?

This is one of the most common misconceptions I see among students preparing for Step 1. If something has helped in the past, then repeating it ad infinitum will increase your score indefinitely.

Repeating UWorld Isn't Better

A little bit of water is good for you. But excessive water isn’t necessarily better.

A Little is Good. More Isn’t Necessarily Better

This sounds reasonable until you consider that it ignores the opportunity cost of spending weeks repeating UWorld over and over.  In other words, every repeated UWorld question prevents you from studying a question from a different question bank. Other questions can 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. 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. However, it tends to be weaker on more recall-type questions that can also be on the USMLEs.

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.

Do UWorld Only Once

UWorld questions are as close to the real thing as possible. Because they’re so close to the real thing, I did NOT do UWorld twice.

A huge challenge for USMLE Step 1 is questions that you have never seen before. Some you may have never even thought about.

This is my real secret to scoring 270 on Step 1. Learn how to reason through questions that you’ve never seen before. Getting never-seen-before questions right differentiates people who are scoring <240 vs. 250-270.

How to Prepare for Questions You’ve Never Seen Before

How can you get questions right you’ve never seen before? By practicing questions that you haven’t seen before.

This might seem obvious. So why do so few people do it? UWorld is similar to USMLEs. However, that does NOT mean that your USMLE will be exactly like every UWorld question.

How many students claim their test was nothing like First Aid/UWorld? Lots. But if UWorld is so much like the USMLE, why are so many students blind-sided? Because they go in thinking the content of the test will be identical to UWorld.

Instead, expect the unexpected. Use UWorld (or other QBanks) to simulate never-before-seen questions.

Full disclosure: I used Kaplan’s Question Bank first. My NBMEs were in the 250s before I even started UWorld. (I only did 2 Qbanks total).  I didn’t repeat either, and didn’t even go through my incorrect questions.

Claim #2: Begin UWorld at Least a Year Before Your Exam

This is a variant of the UFAP refrain: “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. Thus, to score high, drink from their never-ending fount of knowledge as early and as much as.

(To read Beyond UFAP: Why a List of Resources Isn’t a Good Step 1 Strategy, click here).

Doing well on the USMLEs (and Step 1 in particular) involves having as much integrated, applied knowledge of the human body as possible. Furthermore, you must know how to apply it to clinical scenarios.

Introducing a QBank into your studies early in your second year or even late in your first year is useful. However, this definitely does NOT have to be UWorld. (This might even be a waste of UWorld questions; see above).

A 250+ Comes From Applying Pathophysiologic Principles to Questions You’ve Never Seen Before

Remember: I didn’t score 270 on Step 1 by having more knowledge than 99.9% of other medical students. Rather I got really good at applying pathophysiologic principles to questions I had never seen before. By constantly applying knowledge to novel clinical scenarios, I vastly improved my Step 1 score.

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

I repeated incorrect questions twice (once by accident, and once by curiosity). Since I was using Anki, I knew the answer without reading the question. I could also remember the flaw in my reasoning the first time.

Yes, I may have improved my knowledge slightly by repeating the question. However, I learned much less in 30 minutes repeating UWorld than if I’d done 30 minutes Kaplan QBank.

Verdict: Fiction. However, 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

Can any QBank mimic the USMLE’s aim of forcing you to apply knowledge to novel situations? UWorld comes as close as any.

Having been a medical school tutor for years, the difference in quality between Kaplan and UWorld isn’t all that vast. However, if I were to do only one question bank, I would still choose UWorld.

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

Claim #4: “My Test Was NOTHING Like UWorld”

Why do so many students who take the test who come out saying that it was nothing like what they’d prepared for? They say it wasn’t at all like their UWorld questions. But how do others (including myself) claim it was very similar to what they’d expected?

I’ve 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.

UWorld Repeaters Often Believe USMLEs = Tests of Knowledge, Not Application

The students who’ve failed their USMLE often feel that the exam is a test of facts. They think repeating UWorld and First Aid are the best way to accumulate those facts.

The high-scorers know it’s impossible to cover everything they could be tested on. Instead, the know that the point of the exam isn’t knowledge. Instead, scoring high on the USMLEs requires the application of principles. High-scorers recognize that memorization itself is insufficient. They must learn how to apply that knowledge to interpret the test questions correctly.

(To read How Are USMLE Questions Written? 9 Open Secrets for Impressive Boards Scores, click here).

The latter group sees the QBank merely as a means to an end. To them, it’s a practice ground to hone their reasoning skills for the day of the test. In my experience, this group does much better.

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

UWorld Strategy Wrong

Repeating UWorld questions makes it harder to answer items you’ve never seen before.

Claim #5: Use UWorld in Your USMLE Preparations

This is a no-brainer. I completely agree.

Verdict: Definite fact.

Claim #6: Do UWorld Just Before Taking Step 1/Step 2 CK/Step 3

Should you save UWorld for last? Again, like much of the dogma, the answer will depend on what you believe the test to be.

To you, are the USMLEs a test of knowledge? If so, then doing UWorld right before your exam may or may not be as important.

What if you think the USMLEs test your ability to apply knowledge to questions you’ve never seen before? You will likely want to use UWorld as the final question bank before you take your test. (See above; UWorld 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. QBanks are a learning tool, not a repository of facts. Use them 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 UWorld dogma.  It is no doubt an extremely useful question bank. However, 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 your fundamental beliefs about the USMLEs. 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. Rather I saw the exams as a series of carefully constructed questions that would test my ability to integrate and apply pathophysiologic principles.

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

Want to Save Time and Boost Your Score?

Do you lie awake at night, sweating the thought, “I should be studying right now?”  Are you constantly running from activity to activity, feeling like your life is no longer your own?  Do you watch lectures and wonder, “why can’t someone just TEACH me something?”  

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

Photos by Jasper van der Meij, NeONBRAND

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.