How to Retain Information for Step 1

One month after I took my adult echocardiography board exam, I found one of my review books in my car. It was a slim paperback that had fallen under the passenger seat next to a granola bar wrapper. When I picked the book up, it fell open to a page of equations for ultrasound wavelengths. One of these equations was circled in red with a big asterisk next to it. I had apparently marked this equation while studying. But at that moment, a month after my exam, for the life of me, I could swear I had never seen that equation before. It was completely foreign. And yet my own handwriting was on the page, a note to myself that the equation was important to remember. 

The summer after my first year of medical school, I worked in a research lab. While my experiments were running, I flipped through Netter’s Atlas of Anatomy to refresh my memory of the names of muscles, nerves, and blood vessels for Step 1. I studied all the fine details of the Circle of Willis, the brachial plexus, and much, much more. After that summer, I didn’t open the book again for months. By the time Step 1 approached the next May, I had completely forgotten everything. I had to relearn all those nerve and blood vessel names from scratch. Although I had committed them to memory, it was too far out from the test for my learning to be effective. Nothing had stuck. 

I tell you these stories to illustrate the fleeting nature of isolated memorized facts. Information we do not use regularly quickly slips from our mind. I know the names of heart failure drugs because I think about them every day as a cardiologist. But if you ask me for the name of an enzyme in glycolysis, I would have to look it up. Although I memorized it a long time ago, I have not accessed that memory in years. 

If you are struggling to remember all the details for Step 1, don’t get down on yourself. You are totally normal. When preparing for Step 1, there is no point to memorizing facts until about 4 to 6 weeks before your exam. Before this, you can try to memorize all you want, but you will just end up frustrated by how little you recall as time goes by. No one, not your professors in medical school, not even that one student in your class that everyone thinks is “a genius,” can remember facts that they don’t use on a regular basis. 

Some upperclassmen or even practicing MDs will tell you they still remember certain pages from First Aid for the Boards years after their exam because they studied them so much. This will also happen for you for a small number of topics. Because a few things stick in your mind, you may think memorizing more will give you a mental image of everything in First Aid to access during your exam. But this is a fool’s errand. If you try to memorize every page in First Aid through months of drilling, you will only become frustrated by how quickly you forget. 

But if memorization is a waste of time, Dr. Ryan, what am I supposed to do? Nothing?

Just because it’s a waste of time to memorize which bacteria are gram positive and gram negative, doesn’t mean you can’t review microbiology at all. Far out from the test is the ideal time to learn and understand broad concepts: things like how bacteria are categorized, how antibiotics work, how infections produce symptoms, or the immune response to pathogens. This knowledge will allow you to apply what you know, which is exactly what Step 1 will ask of you. When your test is far away, for whatever resource you use—textbooks, review books, videos—don’t worry too much about names and numbers, just the big picture. Leave the itty-bitty details for later. 

    

Once you know the big picture, you can retain fine details more easily. Imagine I told you the names of medications used to treat heart failure, but you knew nothing about the disease. Those names would stick with you a day or two at most. Now imagine you had spent time following heart failure patients in the hospital, and reading about the disease in textbooks. If I told you medication names now, you’d remember them for much longer. Learn the big picture of medicine while you study until it gets very close to your exam. Having a strong base in the big picture concepts and how they connect will set you up to remember more when the time for memorization arrives. 

Once the month or so before your test is upon you, that’s the time to drill facts into your brain. During this period, memorized details will stick until your exam. The last thing you want to do in the month before your test is spend time learning the big picture. Have that down long before then. The weeks before the exam are a golden time for memorizing. Use those precious moments to drill facts with Anki, flash cards, practice questions, or whatever works for you. Just before the exam is the ideal time to fill in the fine details of that broader framework you spent months building in your mind. 

Students who do well on step 1 don’t study more, they study smarter. Memorizing names of muscles, nerves, enzymes, bacteria, or viruses is a poor use of time when the exam is months away. Through all the board exams I have taken (nine!), the same theme has played out. Only the details I studied a few weeks before the test stuck in my mind until the exam. Far out from the exam, time I spent memorizing has always seemed a waste in retrospect. And for those topics where I understood the broad concepts, it was so much easier to commit details to memory just before the test. 

The best approach to Step 1 is to study the big picture and get it down pat, then memorize in the weeks just before your exam. Do this, and you’ll be amazed at how much you remember during the test. Then, weeks later, just like me, you will find your old copy of First Aid under your car seat and wonder who made some of those marks in the margins. 


Jason Ryan, MD

April 22, 2019

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