Dr. Ryan's Step 1 Tips

To reach my current position as a general cardiologist, I have taken nine board exams: Step 1, 2, and 3, Internal Medicine (twice: initial boards and recertification), General Cardiology (twice), Adult Echocardiography, and Nuclear Cardiology. I have also been teaching medical students for over ten years with several colleagues who write questions for the USMLE Step 1 exam. Through this experience, I have observed a number of themes about what works and does not work for board preparation. I share these with you now in the hopes they may help you better prepare for Step 1.

 

There is no recipe for success in board preparation. Every year, tens of thousands of students prepare for the Step 1 exam. If studying from certain resources in a certain way guaranteed a 270, it would have been figured out long ago and everyone would be doing it. There simply is no guaranteed path to a top score. If one student gets a 260 and ten students follow the same study plan exactly, not all 10 will get a similar score, at most just one or two.

When I was in medical school none of the currently available resources except for First Aid existed. Despite that, students achieved scores of 250 and above. I have seen current students use all available resources—Boards and Beyond, UWorld, Sketchy, Pathoma, Anki—and still wind up disappointed in their score. This is a cliché, but it’s not the resource that matters, it’s how you use it.

Because there is no recipe for success, you should never feel compelled to use any particular resource. Use only what works for you. It's fine to explore resources based on suggestions of other students but don't feel compelled to use them. Since nothing guarantees success, skipping a resource doesn’t guarantee failure. Some students feel they must use particular resources because “everyone is using it.” Don’t do this. No resource holds secrets to answering questions. Choose what works for you.

While preparing for Step 1, avoid talking with your classmates about your progress. Many students want to know where they stand. Are others preparing the same way as me? How am I progressing compared with my class? But asking classmates about board prep will only stress you out. Few of us are completely honest about our struggles and weaknesses. If you ask a friend, “How’s your studying going?” they will likely respond, “Oh, pretty good. I’m working my way through a few topics like…” They are far less likely to say, “Ugh. I just bombed a block of UWorld and tanked my last NBME. I can’t understand this physiology stuff at all…” It is human nature to share the good and conceal the bad about ourselves.

As another example, many students who score 250 and above share their experiences with others. Almost no one who scores 200 shares anything. If you go around asking people about their Step 1 efforts, you will get an excess of positive spin and success stories. This will make you feel like everyone has it together better than you. And remember, there is no recipe for success so no one is going to tell you something that magically leads to a top score.

I have seen this time and again over the years: the best students tuck themselves away and study hidden from their peers. Maybe they study with a close friend or two but that’s it. They rarely talk about their study plan, or ask others about theirs. The focus on their work and don't get distracted by comparisons with others. These students always seem to end up with the highest scores. 

Earning a top score on board exams requires guessing. Let’s suppose you need to answer 75% of questions correctly for a 250 on Step 1. One way to do this is by knowing the answer cold to 75% of the questions such that once you read the question you immediately know the answer. This is very unlikely. The material is too vast, the questions too complex. A second way to get 75% correct is to know the answer cold to 50% of questions, a more reasonable goal. For the remaining 50% of questions, narrow the answer choices down to two and guess. Statistically, you will get 50% of these correct leading to the 75% score you need.

75% Correct (answered easily) + 25% Incorrect (no idea of answer) = 75% correct

50% Correct (answered easily) + 50% Guess (two answers = half correct) = 75% correct

If you can’t narrow the choices to two answers, narrow to three. Do anything you can to increase your chances when you guess. On every board exam no matter how much you prepare there will be guessing. Don’t panic. Guessing is not an indication of poor preparation, it’s normal. You must get comfortable narrowing down the answers and guessing if you want a top score on Step 1.

In general, be prepared for many questions on exam day where the answer is not immediately obvious. Some students go through dozens of resources hoping to “see everything” before their exam. This cannot be done. No matter how intense your studying, unfamiliar material will be on your exam. You will have to use reason and logic to find the answer, not just recall. Get used to this idea. This will happen on Step 1 and every other board exam in your career.

Memorization will only get you so far. USMLE question writers are specifically instructed to avoid testing easily-memorized facts. The exam’s goal is to test understanding of medical science not recall. Few questions will ask you to simply name a disease, pathogen, or enzyme from memory. It’s more likely you will be asked to apply a concept to an unfamiliar scenario, something that’s very difficult to do purely from recall. While memorized facts may help to some degree, you will do much better if you to understand WHY a memorized fact is important rather than just the fact itself.

Step 1 is a test of mechanisms. You will rarely be asked to choose the best diagnostic test or decide if surgery is indicated on Step 1. Questions usually describe a clinical scenario and ask about what’s happening at the organ, cellular, or molecular level. The exam tests your understanding of how diseases and drugs work. Keep this in mind as you study. Focus on basic aspects of diseases and drugs like whether proteins, lipids, or carbohydrates are involved, or whether the process is infectious, neoplastic, or inflammatory.  Higher-level clinical knowledge is not emphasized on Step 1. If you do see questions asking about clinical management of patients, they can usually be answered from knowledge of the underlying mechanism of disease.

You will only see classic disease presentations on Step 1. I once saw a man with a toothache whose symptoms were caused by myocardial ischemia. You will never see a case like this on Step 1. Every myocardial infarction will present will squeezing substernal chest pain. The boards only use classic presentations of disease on the Step 1 exam. Students at this level are not expected to recognize bizarre, unusual signs and symptoms. When learning about a disease, focus on the classic, typical presentation. 

There are lots of experimental questions on board exams that don’t count toward your score. The boards need questions that “discriminate” among strong and weak test takers. The best questions are answered correctly by students who score highly on the test overall, and answered incorrectly by students who perform poorly (see page 21 here).  These allow the boards to separate students into groups that can be assigned a score. To find good questions, many experimental questions are placed throughout your test to collect data. Lots of these are later thrown out because of poor performance. A colleague of mine wrote a question for Step 1 that only 5% of test takers answered correctly. It was ultimately thrown out, but only after a few thousand students answered it for data collection purposes. Many of those students probably left their exam ruminating over this question. Experimental questions like these can account for as many as 20% of your exam and they don’t count toward your score. Don’t panic during the test if you see a bizarre question. And don’t base your study plan around comments from other students like, “I had a crazy question on my exam about…” 

Step 1 questions are constantly changing.  Step 1 questions are written by USMLE committees of faculty members from medical schools. Committee members are paid a small stipend (about $1000 a year) and travel to national meetings regularly. These committees write new questions and also review old ones. Questions are reused year to year but may be removed for many reasons. If science changes, old questions may no longer apply. If a question becomes too easy (i.e., is answered correctly by almost all students), the question is removed because questions that everyone gets right are not useful for separating students into high and low performers. Because questions change, you should avoid listening to what students tell you about past exams. Many questions from previous exams are no longer in circulation. In addition, the USMLE question bank is so large it’s highly unlikely you will see the same question as another student. 

About half of the questions on boards are relatively easy. The boards need a range of question difficulty to spread students out in terms of scores. All questions cannot be brain twisters. Even though tricky, super-difficult questions are much discussed among medical students, not every question is like this. In my experience, about half the questions on all board exams are straightforward. If you put in solid work to prepare, you will get these questions right.

Unfortunately, it’s the hard questions everyone remembers after the test. When you leave your exam, you’ll remember a handful of the most difficult questions forgetting the easy ones. This will leave you with a terrible feeling. Remember that you most likely answered many questions correctly, they just aren’t the ones that stick with you after the test. Also keep in mind that many questions are experimental (see above) and don’t count toward your score. 

More than 90% of what you study will not appear on your exam. You can pound pulmonary physiology into your brain only to see no questions about this on your test. With only a few hundred questions, the boards cannot even come close to covering every potential Step 1 topic. When you begin to study, do your best to understand everything. But as the test gets near, don’t worry if one particular topic is giving you trouble. It likely won’t appear on your exam. The weeks before the test are a golden time for memorizing and solidifying material. Don’t get sidetracked by one difficult topic.  

Also, one test can look VERY different from another with so many topics to choose from. Don't build your study plan around someone saying, "On my exam, I didn't have any questions about  {biochem, pneumonia, EKGs, etc.}..." That was their test. Yours may look a lot different. 

Reading comprehension and vocabulary skills are important . Once a student told me he believed he had found a practice question with two right answers. The question was something like this: Which of the following is an endogenous trigger for inflammation? The student thought bacterial lipopolysaccharides and cytokines were both correct answer choices. The student’s error was missing the word endogenous meaning from within the body. Maybe he didn’t know what the word meant. Maybe he skimmed past the word as he read. Another student showed me a question where she thought the word attenuate meant the same thing as accentuate when in fact these words are opposites. And, of course, one of the incorrect answer choices fit perfectly if you made this reading mistake.

It’s very easy to choose incorrect answers due to misreading of questions and answer choices. The boards often use tricky language to make the exam more difficult. Many students focus on high yield facts and underappreciate how important language skills are. After the exam, students often tell me they knew the answer to certain questions but couldn’t find the answer among the choices. These are often issues related to tricky wording of the question stem or answer choices.

One way to avoid language errors is to read questions carefully. Another way it to develop solid reading and vocabulary skills, skills you can’t obtain by drilling flash cards or watching videos. Many students neglect textbooks now that video learning is widely available, but there are good reasons not to ignore textbooks altogether. You may dislike struggling through a dense chapter of Robbins but this is similar to what the boards will ask of you. Textbook authors use scientific words and sophisticated vocabulary just like you will see on your exam. Although review resources contain many high-yield facts they simplify the language.  The best students I have advised over the years have been avid readers of textbooks in addition to the usual board prep materials.

The boards love questions about data interpretation. You may know that insulin causes serum glucose levels to fall. Can you picture this on a graph? If you were shown a data table with glucose concentration in one column and insulin in another could you recognize the relationship? As you study, try to avoid learning relationships only as laws like “insulin lowers glucose.” Remember that these relationships were established from experimental data. Try to picture what those data would look like in a table or on a graph. It’s very likely this is how it will be shown to you on the boards.

This is another good reason to spend some time reading textbooks alongside board prep materials. These often show primary data, especially if those data are famous for establishing principles of medical science.  Within textbooks you will see tables, graphs, and pathology images, many of them similar to those you will see on your exam.

The boards are using more and more clinical images. Increasingly, students are seeing X-rays, CT scans, and MRIs on Step 1. These often strike fear among students who find images challenging (which is basically every student; what student says, “Hey look, a sagittal MRI of the mediastinum. These are easy.”). Here’s the trick to these questions: USMLE question writers know that medical students are not radiologists. Images on the exam will be classic, easily-identifiable examples of common pathology. What’s more, you can often answer the question without the image. Read the question carefully focusing on patient demographics, symptoms, and signs. Then think of the big picture regarding the image: Is it of the brain? The chest? The extremities? With this information you can probably pick the right answer or at least narrow down to a couple of choices (see my advice on guessing above). Whatever you do, don’t panic and think: “Oh, my god! I’ve never seen a coronal MRI of the abdomen! I am doomed!” If you do this, you will miss clues in the question that often lead easily to the right answer.

Step 1 is not your destiny. Many poor test takers have become outstanding, highly-successful physicians. And students with weak scores can still get into competitive residencies through research or other avenues. Furthermore, after Step 1 comes Step 2 and Step 3 and then internship, residency, and fellowship. The opportunities to compete in medicine never end. This can be very hard on those who feel compelled to be the best. Physician burnout is a major problem. One of the reasons for this is the pressure we put on ourselves to always be the best. Lower the stakes. Shoot for the best score you can get but find a way to be happy with whatever happens. Taking away the pressure will make your studying more effective. And finding happiness that does not require validation from tests or awards will lead to a more fulfilling career.

 

All of these views are solely my own. I hope you find them helpful but if they do not ring true, please ignore them. Ultimately, board preparation is a personal journey of expanding our minds to understand the beautiful complexity of the human body. May you find a path that leads to success and happiness.

 

Jason Ryan, MD

July 30, 2018

 

"Boards and Beyond was one of the best resources I used in preparing for Step 1."
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