Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Preparing for and taking USMLE Step I

For US medical students who are in the beginnings of the second semester, or final weeks before your break to study for USMLE Step I, I have put some thoughts below, that will help you start thinking about preparation for Step I. You should have obtained (online) the bulletin for USMLE Step I and you should be thoroughly familiar with the procedures for taking this important exam. At this point, you want to finish your coursework strongly and begin thinking about your time frame for taking this exam. This exam should be respected but not feared. It is but one step in your career, that is, a career that will have many steps like USMLE Step I but this exam is very doable and should be given some solid preparation time. In short, don’t rush or make mistakes in your preparation process.

Most people who are taking the United States Medical Licensure Exam Step I (USMLE Step I) will take this exam after completing the basic science component of their medical school coursework. For many students, this will come at the end of Year 2 and for some, this test will come at the end of 1.5 years of coursework. No matter when this test comes for you, make no mistake, this test takes some preparation regardless of your coursework performance. For medical students who have attended an LCME-accredited medical school, you have the assurance that your school has provided the coursework content that you need to pass USMLE Step I. With additional review and preparation, those who have attended an LCME-accredited medical school can excel on this test. The key is review and preparation.

The first and most important component of your preparation for USMLE Step I is to master thoroughly your coursework. When you start medical school, through mastery of your coursework is your main goal and this does not run “counter” to preparation for USMLE Step I. Additionally, in your thorough mastery of your coursework, do not make the mistake of attempting to “memorize” USMLE Step I review books during your coursework mastery stage. You have plenty of time to utilize review books at the end of your course blocks.

It is very tempting to purchase USMLE Step I review books during your medical school orientation for use as you are going through your coursework but do not make the mistake of believing that what is in the review book is all that you need to know from your coursework. Review books are designed to “review” materials and one cannot “review” what one has not mastered in the first place. Again, having a review book such as “First Aid for Step I” is not counter to mastery of your coursework but a review book should not take away from your main study strategies in your courses.

The best use of review books is when you have completed your subject matter. For most students in integrated curricula, review books that are not integrated are not as useful. While a review book can give highlights of specific subjects, they are generally not integrated as much as your coursework will be. The other problem with review books is that they are deliberately written to give the major points without much detail. During the coursework mastery phase of your medical training, you need the details. Once mastered, you can refresh your recall of the details with a review. If you are finding that you need more details, then use a denser resource than a review book. You likely do not need to return to your textbook but you might need to look at note summaries or books such as the Costanzo’s Physiology or Goljan’s Rapid Review of Pathology that are of medium density.

Another mistake that many pre-testers of USMLE Step I will make is improperly utilizing question banks as their preparation for this exam. Question Bank-type preparation is great for pointing out knowledge gap needs in your study but do not utilize question banks as a means of learning the material. If you are missing a great number of questions on a question bank service, especially in a particular subject, you likely need to move to a medium-density preparation book. Even intensive prep courses will not overcome significant knowledge gaps as the coursework content needed for this exam takes 1.5 to 2 years and can’t be duplicated in a few weeks (typical length of intensive review courses).

Many pre-testers tend to memorize the right and wrong answers to specific questions rather than going to a strong review book, something more than an outline, for knowledge acquisition. The best use of question banks is to first point out your deficiencies and second, to get your brain used to thinking in the manner that USMLE Step I will test. A good question bank service should trigger your brain to analyze cases and apply your knowledge not feed you answers to specific questions.

If you are utilizing a particular Question Bank service and monitoring your scores with the sense that if you are getting a certain percentage, you are assured of a strong USMLE Step I performance, you may be living in a world of false security. I have had more than a few students stop by my office to report that they are scoring 70% and 80% on a specific question bank service only to find that their score on the actual test is much lower than they expected by their test bank performances. I suspect that the reason for the discrepancy in scores is that these students relied too much on the content of the question bank rather than on what the overall trend of the question bank was pointing out, i.e. that they had some gaps in their knowledge that needed solid preparation.

Now, what do I mean by “solid” preparation? This “solidification of preparation”  can be pretty elusive for some people but in general, the people who are solidly prepared have an “approach” to how the identify the correct answers on USMLE Step I. This “approach” allows them to even take “educated” guesses on things that they can’t readily recall and allows them to quickly recall the materials that they need to answer the questions correctly.

Solid preparation takes a very strong knowledge base and knowledge/practice of how USMLE Step I will test that knowledge base. Again, if you have attended an LCME-accredited medical school and have thoroughly mastered your coursework, you have the knowledge base that you need to score well on that test. Your review should be focused on the development of a means of analysis of distracters in questions (Question Banks can help with this but use  a question bank that utilizes case-based questions and more than one manner of questioning) and the application of your analytic/critical thinking skills. Armed with these materials, you are well on your way to a very strong performance. Remember, you want your Question Bank to challenge you with as many methods as possible during your review time.

Your other ingredient in your “strong” preparation for this test is the confidence that you can sit down, take each question as it comes, select the BEST answer to each question and move on to the next question on the computer. Remember, every question counts the same so there is no penalty for “guessing” but there are huge penalties for leaving questions unanswered because you ran out of time.

In short, you have to be able to answer your questions correctly and efficiently so that the clock is not your enemy. Again, plenty of practice questions is a good strategy for analyzing your question-answering abilities in terms of timing. Unanswered questions are always wrong answers but you might be able to guess the correct answer if you have been able to get to the question. Don’t leave any questions unanswered is the moral of this story which means that you have to have a strategy that allows you to at least “read” every question in each block at least once. Utilize your question banks to increase your efficiency of question analysis plus increasing your percentages of correct answers. You want to see an improvement in both time and reasoning.

Your next goal in USMLE Step I preparation is not to allow yourself to become emotionally “blocked” if you encounter something that you do not recognize in a question. There will be questions that contain material that you will not know which means that you mark that question and move onto the next question (likely will have something that you know). If you keep encountering questions with materials that you don’t recognize, note the subject matter (if you are using a test bank) and review those subjects as needed.  If you are on the actual exam, keep moving forward as you can always return to the questions that you have “flagged” if you work efficiently with time moving from question to question without emotion. In short, emoting over questions is a poor utilization of your time and blocks your ability to reason.

As long as you have not exhausted your time in a particular question block, you can return to marked unanswered questions and have another shot at narrowing down the answer choices. Most of the times, as you move through a block, something further down the block will trigger knowledge that will enable you to return to a question and see the correct answer even if it eluded you on first read.

Resist the impulse to change answers unless you have a very compelling reason. Compelling reasons are that you remembered something that is key to answering that particular question or that you see something in the question that you previously missed on first read.  If you find that you are missing things on first read through, slow down a bit, take a couple of breaths and focus on what each individual question is asking. Many people jump to what they “believe” the question is answering rather than what’s actually on the page. Again, if you don’t spend too much time on any one question, you should have plenty of time to go back and review your questions and answers in each block before you leave a particular block.

If you are finishing question blocks early, take the time to review each question and your answer so that you can be confident that you HAVE chosen the correct answer. The worst possible outcomes will happen when you are rushing through the questions and missing key evidence that points out the correct answer. You want to finish each block with enough time to review each question and assure that you have marked what you wanted to mark for each question. In short, don’t move so quickly that you make clerical errors in marking your answers.

I also cannot emphasize the importance of not taking USMLE Step I until you have completed your required coursework and until you have completed a systematic and thorough review. USMLE Step I is likely to test differently from your coursework but a strong knowledge base that you can apply to the questions will help you score well on this important test. If you do not feel prepared, that is, you feel that your preparation has been rushed or inadequate, change your test date but don’t keep “putting off the test” because you don’t feel 100% prepared. You should feel that you were able to review things that you needed to review but one never feels totally prepared for every step of USMLE. You have to reach a point of saturation and satiety in terms of mastering what you need but resist waiting for the “magical moment of total confidence” because it never comes.

Will you ever feel totally confident that you know everything on this test? No, you need to have a healthy respect for this exam. You also need to walk into that computer center with the feeling that you have mastered your coursework and review and that you will take each question as it comes. You can’t be paralyzed about the consequences of failure or of not getting the score that you wanted. You can be philosophical in terms of you are ready to give the exam your best shot and that is what you are going to do.  You simply have to prepare and move forward and look at USMLE Step I as just another step in your preparation to become the physician that you want to be.


3 January, 2013 - Posted by | academics, medical school coursework, USMLE, USMLE Step 1 |

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