Training for Marathon USMLE Exams

Alex Millman, MD


January 23, 2012


I'm trying to prepare for the USMLE Step 1, but I'm having trouble focusing on the endless number of questions. How can I ramp up my endurance?

Response from Alex Millman, MD
Resident Physician, University of California, San Francisco

You'll take many tests while training to become a physician. However, 3 board exams taken over the course of medical school and residency have a particular resonance with trainees: the United States Medical Licensing Examination (USMLE) Steps I, II, and III.

These comprehensive, challenging, and time-consuming tests "assess a physician's ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease and that constitute the basis of safe and effective patient care," according to the USMLE's own overview. Not surprisingly, these exams last longer than 8 hours.

Preparing for the USMLE is challenging because you must synthesize large quantities of material as well as build up your test-taking endurance. There are many resources that will help you with content, so I will focus on how you can improve your stamina for lengthy exams.

The most important advice is to treat preparation like training for a marathon. First, familiarize yourself with the content and the format of the exam itself. Although this might seem obvious, the National Board of Medical Examiners periodically announces changes to the number of questions per section and the total time of the exam. Checking on any changes ahead of time is an easy way to minimize surprises.

Your main preparation tool is a question bank. Kaplan and USMLE World are 2 of the largest commercially available question banks. The National Board of Medical Examiners also produces its own practice materials.

There are many opinions on the "best way" to use these resources, but in my experience, doing questions is highly effective for learning the material and building up test-taking stamina. The main goal should be to try to mimic the conditions of the test as best as possible.

My own training regimen was to gradually increase the number of questions I did at once, with the goal of taking a full-length test several days prior to the actual exam.

I answered all questions in timed, nontutor mode to have the experience mimic the real test as closely as possible. (I would wait to review all the answers at the end of the test.) This strategy allowed me to figure out how to pace myself and how not to obsess over questions that I did not know the answers to.

In the early stages of my studying, I would do sets of questions with a number equivalent to a section on the actual exam.

As it got closer to the test date, I would ramp up the number of questions to equate to the number on 2 or 3 sections of the test. About 2 weeks before the test date, I would try to do a half-test equivalent of questions.

Several days prior to the test, I did a full-length exam. I tried to mimic the test conditions as best as I could by eliminating distractions from my study environment and allowing myself to take breaks between sets of questions. (This also meant eating, drinking, and using the bathroom only during break time.)

Although you run the risk of question fatigue, you may find this method to be extremely helpful to prepare for the actual test day with its mentally exhausting, seemingly endless number of questions.

On the day before the test, do not study! Simply relax and do something you enjoy. If you have not done so already, make sure to check how to get to your testing center, print out your testing permit, prepare your lunch and snacks for the next day, and get a good night's sleep.

If you have built up your stamina, you should have a good sense of how quickly you work and when you should time your breaks. Everybody is different when it comes to needing break time and eating during the test; however, you should feel comfortable with making those decisions if you have practiced in conditions similar to the actual exam.

Similarly, the test day is not a day innovate. If you normally eat breakfast every morning, don't skip it. Although deviating from a routine is great in some aspects of life, this is not one of them.

At the end of the test, you will be exhausted and likely think that you failed. (Everyone I have spoken to feels the same when he or she leaves.) Rather than dwelling on these negative feelings, take the opportunity to go out and celebrate.