The 4 Things Every USMLE Candidate Needs to Get Right

I think of USMLE prep as a platform on four pillars supporting a heavy object. The object in this metaphor represents the competency candidates need to excel on the exams. The pillars represent four tasks that candidates must successfully complete if the goal of holding up the heavy object is to be realized. The four tasks are; choosing content, mastering content, retaining content, and applying content. When I take on a new student to prep for the USMLE step 1 or step 2 CK, the study plan we agree on is always designed to ensure high-quality execution in these four areas. Once that is accomplished, any candidate will be ready for the exam. Let’s explore these four tasks in more detail.

1. Choosing content

Selecting what resources to base your USMLE prep on is the easiest of the four tasks we will discuss. This is because of near-ubiquitous access to high-quality resources these days. Unfortunately, the plethora of choices often causes candidates to select far too many resources or the wrong options for their unique situation. Considering the hundreds to thousands of hours you will invest in these resources, choosing the ones with the highest return on investment for your situation is necessary. The right resources will enhance your prep, while the wrong ones will be detrimental.

Like myself, my students are mostly IMGs and students at foreign medical schools, so the advice below is tailored for this population of candidates.

I tell my students that there are three types of primary resources and a few secondary resources for USMLE prep. The primary resources are so-called because every IMG will need at least one resource of each type. The secondary resources are optional, and the decision to use them depends on each candidate’s unique situation and preferences.

The three primary resource categories are lecture or video-based review, text-based review, and Q-banks. The categories have unique purposes that occasionally overlap with one another. These purposes are also related to the other three pillars of USMLE prep that we will outline. IMGs often come from systems where they have practiced medicine for years after med school before deciding to take the USMLE. In the case of medical students outside the US, the curricula, academic structures, and calendars are often not optimized to lay a solid USMLE foundation. This might be due to optimization for the medical system of the home country or questionable academic standards.

Consequently, candidates often have to invest considerable time and resources in building up mastery of USMLE concepts. This is where live and on-demand lectures come in. A common and unfortunate mistake that candidates often make is to “study” First Aid for mastery. First aid is an excellent review resource but a terrible learning resource, so trying to use it to build mastery will likely result in cramming and eventual frustration. Once initial mastery has been attained, text-based reviews such as First Aid are essential for finding and filling knowledge gaps and for long-term retention by spaced repetition. Q-banks function to support all three of the other pillars (mastery, retention, and test-taking skills). Since Q-banks are the only resource candidates can use to bolster test-taking skills, they become vital for this task, but more on that later.

There are myriad choices in each category, often from the same entity, but the text-based review and Q-banks are the most consistent among candidates. Most people will use First Aid as their textbooks and uWorld as their Q-bank. This is unsurprising since both are excellent, gold-standard resources in their categories. That said, there are other terrific options for text and Q-bank. They can achieve similar outcomes if appropriately utilized, as First Aid and uWorld would have to be.

An example of an alternative to first aid is Kaplan’s 7-set lecture notes for step 1. I have gone through every word in both texts, and they are each as complete as the other. A similar thing can be said of Kaplan’s step 1 question bank, which does not lack any concepts found in uWorld. The difference between the uWorld and Kaplan Q-banks is that uWorld explanations are significantly more concise. In contrast, Kaplan’s explanations aim to provide a more comprehensive review of each concept in their questions. In the days that step 1 had 3-digit scores, my recommendation for choosing between uWorld and Kaplan depended on the target score. Kaplan is designed as though everyone who uses it aims to score 250 and above on step 1, which is not the case. For most candidates, uWorld was a significantly more efficient resource. Other Q-banks include Rx, Lecturio, Boards & Beyond, Amboss, SmashUSMLE, and more. These resources each have their strengths and weaknesses. They also often come with live or on-demand lectures and text-based resources, or in some cases, both. As shown in the example above, my recommendations to my students depend on both the pros and cons of each option and the candidate’s unique academic and budgetary requirements.

The secondary resources are used to bolster mastery, retention, and test-taking objectives. Anki, for instance, is a popular resource for retention exercises. Candidates swear by pathoma when it comes to understanding and reviewing concepts in pathology. Sketchy microbiology is also a popular option for memorizing essential concepts in microbiology. Osmosis is suitable for targeted review of specific physio, path, and pharm concepts. There is a channel on YouTube called Medzcool that is a Godsend for learning the heart sounds you are sure to encounter on the exams. Amboss and Medbullets are excellent for looking up concepts. The list goes on, and use cases vary widely from candidate to candidate.

2. Mastering content

Mastery refers to the increase in your understanding of a concept, topic, or chapter after you study it. An easy way to think of it is to ask, “if you took a test on this organ system before and after you studied it, how much would your score go up?” I often implement this question practically by having my students answer an entire block of 40 questions before and after a given study goal. For example, a student could take 40 cardiovascular questions before beginning the cardiovascular chapter. They would then take 40 questions after, for comparative analysis. I recommend a staggered approach to practice questions. This approach holds that candidates should only use practice questions after the tested concepts have been studied and reviewed using lecture and text-based resources. This means the hypothetical student studying the cardiology chapter would be doing daily practice questions not in cardiology, but from the chapter they most recently completed before it (Pulmonology, for example). The reasons for this are discussed in another article. The result is that the score increase measured at the end of the chapter is a direct indication of the effectiveness of the approach to mastery during that chapter. If there is an insufficient increase in performance, the reasons why would have to be identified and addressed in a follow-up coaching session.

This strategy flies in the face of the conventional wisdom among USMLE candidates and experts that discourages using Q-banks as an assessment tool. I believe that advice would serve candidates better by discouraging using Q-banks PRIMARILY as an assessment tool. Their primary purpose is undoubtedly to promote understanding, retention, and test-taking skills. Still, they can provide highly accurate insight into the candidate’s trajectory. Too often, candidates go through the motions of prepping and only have an accurate assessment of their performance once they take a standardized self-assessment. These assessments are invaluable, but because of the volume of information they test and the time that often passes between them, their temporal resolution is often too low to allow day-to-day or week-to-week course corrections. These course corrections are essential for excellence on the exams.

The most basic level of USMLE prep is reviewing an individual concept (fetal circulation, for example). At this level, a reliable way of checking mastery is to see if you can teach the concept to someone else or yourself without looking at the information, and with minimal to no knowledge gaps. For example, if you can outline fetal circulation starting at the umbilical veins and back through the umbilical artery while only forgetting one detail, you have achieved sufficient mastery. On the other hand, if you struggle with explaining most steps in the circulation, then you need to understand it better for USMLE-style questions. This technique has the advantage of forcing active instead of passive studying. It allows you to identify and plug knowledge gaps in a concept before moving on from it. The biggest obstacle to effectively using this technique will be the time it adds and the discipline to dedicate that time. My advice to my students is to prioritize mastery over speed because speed is eventually a natural consequence of mastery. Prioritizing speed at the beginning will have a feel-good result due to perceived progress but will likely result in numerous knowledge gaps that impede performance.

3. Retaining content

Candidates for the USMLE will usually begin their preparations months in advance of test day. That long timeline and the sheer volume of material pose a significant challenge to long-term memory. Beyond test day, physicians must retain a good chunk of this information for life. Unlike other aspects of USMLE prep which candidates can approach in multiple ways, there is only one answer to building a solid long-term memory: effective and spaced repetition.

In my experience, the most common advice among USMLE candidates for implementing spaced repetition is to have multiple “passes” through First-Aid and the Q-bank, usually uWorld. This idea is valid but poses two significant obstacles to the objective it aims to reach. Working through First Aid linearly from the first page to the last often takes considerable time. By the end of the book, candidates have often forgotten much of the information in the first half. When they return to the beginning for a “second pass,” they will have forgotten much of the information in the second half by the time they reach the middle of the book. Rinse, repeat and hope for the best is the strategy candidates often adopt in this scenario.

The solution to the cycle of learning and forgetting that candidates often find themselves in is to shorten the duration between repetitions of the same concept. The key is to review content before you have had a chance to forget it. This means dedicating about 30% of study time to a 2-steps-forward-1-step back approach. Candidates will also need multiple layers of repetition. In practice, this can look like taking one day off every week to review the content covered that week and then 2-3 days off each month to cover the material studied in the last four weeks. After 8 weeks, a candidate might again dedicate 2-3 days to review the material reviewed in the first four weeks, in addition to other weekly and monthly reviews they are due for at that time.

As with the mastery exercise, the perceived time required to implement this method is the biggest impediment to compliance since candidates often want to cover more new material. Suppose the patience and discipline necessary for effective spaced repetition are applied, though. In that case, there should be excellent retention of the required basic science material by the end of the “first pass” through the text-based review, whether First Aid or something else. There would have been multiple repetitions of each concept, achieving the same goal as the advice to do multiple passes, but with higher effectiveness.

Regarding multiple passes through a Q-bank, it is more beneficial to mastery and test-taking skills to see, for example, 8000 unique questions than to do 4000 questions twice. For this reason, I strongly discourage multiple passes through one Q-bank.

Other layers of spaced repetition exist in the form of flashcards, Q-bank explanations, and the aforementioned staggered approach to questions. I recommend students create their own flashcards and avoid pre-made decks. This is because flashcards are best utilized for content that is both difficult to remember (like interleukin functions) and is not already familiar to the candidate. The coagulation cascade, for instance, is difficult to remember. Still, I am familiar with it, so it should not be part of my flashcard deck, whereas it might be recommended for someone else. This means that the optimal deck for any one person will be unique to them. Interestingly there is research to back this up, which demonstrated that user-generated flashcards are associated with better USMLE performance, whereas ready-made decks are not.

4. Applying content

After choosing the right content and applying the right strategies to mastery and retention, you will be faced with using all that information to answer USMLE-style questions on test day. The USMLE and other exams like it are unique in that your test-taking skills are almost as crucial to success as your actual competency in the subject matter. Bolstering test-taking skills requires a deliberate investment of time and effort to which candidates need to pay attention. I expand on how to do this in separate articles, so I will link them here and here.

In conclusion

If you’ve stuck with me till this point, then thanks for reading! I hope this article leaves you a little better equipped for your USMLE journey. I would love to hear your thoughts, positive or negative, so please consider leaving a comment. In addition, if you are considering personalized guidance during your USMLE prep, you can schedule a free consult here.

One thought on “The 4 Things Every USMLE Candidate Needs to Get Right

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