5 Steps to Acing the USMLE Step 1

Rishi Desai, MD, MPH


November 18, 2016

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Editor's note: This video was originally created for use on osmosis, a site intended to assist medical students with learning. For additional content from Osmosis hosted by Medscape, see our partnership page.

Hi. My name is Rishi Desai, and I'm here to give you a few high-yield tips for the United States Medical Licensing Examination (USMLE) Step 1. First off, doing well takes a lot of hard work and a lot of confidence. With that in mind, I've seen students score in the 260s and 270s, and you can too. What I want to do is tell you a little bit about my experience and how I approach exams in general.

My Background

I grew up skipping grades and taking high-stakes exams. It has been a big part of my identity. I took the SAT when I was 12, the MCAT when I was 16, and the USMLE Step 1 when I was 22, and I want to show you how I approach these tests. I've also worked with and trained medical students from all over the country: UC San Francisco, Harvard University, Boston University, University of Southern California, UCLA, and Emory University. I was leading Khan Academy medicine for a number of years, and now I'm a Stanford pediatric infectious disease attending, as well as chief medical officer at Osmosis. So, I feel like I've gotten to know the medical education space really well.

One thing to keep in mind right off the bat is that the National Board of Medical Examiners (NBME) has announced that their exam is going to be a maximum of 40 questions in a block, and there are going to be seven blocks for a total of 280 questions in a day. People have wondered if that means longer vignettes. Nobody knows for certain if that is the case, but the facts are that there are key changes to things like the user interface. These are changes that you can familiarize yourself with. They're going to have a bigger font. They're going to allow you to switch between a black and a white background, so you can see which one you like better, what's easier on the eyes. They're allowing you to zoom in on images and there's a tutorial on how to do this, so check that out and play around with the keyboard shortcuts. Basically, get more familiar with how to use it so you don't feel flustered on the day of the exam or feel like you've never seen it before.

Step 1: Be a Good Student

So, let's get into the nitty-gritty of USMLE Step 1. I've come up with a five-step strategy to doing really well on the test, and I will walk you through it. I'm going to talk about Osmosis because that's the platform that I know best, but we're going to talk about other platforms and content as well so that you can see how it all makes sense together. Let's start with step 1.

Step 1 is early on, 5-20 months before you take the test. It's early first-year medical school or the first part of second year. At this point, just be a good medical student. Enjoy your classes, enjoy your life, and don't stress people out by talking about USMLE immediately after the white coat ceremony. Try not to do that. If you are the closet gunner, if I'm talking to you, then I would say try to stay in the closet. Don't freak people out. There's no need for that. In the old days, people used to buy the book First Aid and rip the binding off. They'd do the same thing with Pathoma. They would three-hole-punch it and open it up and highlight and annotate, and that was good 20 years ago. Today, it's a much better system to just do it all electronically. It allows you to search automatically for keywords in your notes, so later on down the road when you're searching through your notes, you can find them much more easily. I recommend that you do that early on when you're in medical school. It may seem trivial, but when you've jotted something down, and then 2 years later you're looking for it and you can't find it, it wastes a lot of time because you're trying to decipher words in your notes from who knows when. Just searching automatically is really great.

You should also consider using a system that allows you to automatically search your notes. Osmosis handles this by automatically tagging your personal notes to your course work, so that's huge. You can quickly find it and find the exact PowerPoint where you learned that particular concept. The other thing is spaced repetition. You want to make sure to use some sort of platform that allows you to do free space repetition, ideally. It helps with long-term retention. The research points that out very clearly, and if you do that through medical school, you're going to be in good shape. The data show that this is the way to go. You don't want to be highlighting and annotating. You want spaced repetition so that you're focusing on the areas that you are struggling with rather than just doing the stuff that you know really well over and over again. ANKI, Quizlet, and Osmosis Basic are all free of charge. Of the three, I know Osmosis Basic the best. It allows you to create flashcards along with your course documents, right alongside of what you are doing in school. It also lets you crowdsource questions easily, so you can answer questions that other people in the class have written. I want you to get into this habit for a few reasons. One is that it's easy to answer questions you've written, but you want to start seeing how other people would phrase something. It really does become much more challenging, so force yourself to do that if you can. It sets you up really well for when you're studying for the USMLE Step 1; you've already practiced a lot of this skill-building and you're ready to go.

Step 2: Start Studying

Step 2 starts 3-5 months before test day. At this point, you're trying to figure out which question banks you should use. The two that I would recommend are UWorld and the NBME, and together there are about 4000 questions. You want to do a couple of NBMEs to figure out where your strengths and weaknesses are so you will know what to focus on. You also want to do additional practice boards questions. You don't want to use up all of your UWorld questions at this point, so I recommend that you look at one of the other question banks. For example, Osmosis has a question bank of more than 3000 questions. Qmax and Kaplan Qbank each have about 2000 questions. It doesn't matter which one you choose. You want to use these for learning, primarily.

One thing that I've come to really enjoy about Osmosis questions is that they allow you to figure out your confidence level before you answer the question. It asks you how confident you are, and then you click whatever the answer is. It's important to answer the confidence question before so that you can focus on the stuff you're not confident about as well as the stuff you're getting wrong. I want you to really drill into those two buckets of questions and ask, "Why was I not confident about that? Why was I getting that wrong?" Go and find learning resources that can help you figure those things out. The classic learning resources that I'm sure you're familiar with are Costanzo for physiology, Pathoma for pathophysiology, Doctors in Training (DIT), High-Yield books, and Lange flashcards-whatever you need. A lot of these cost money, and I realize that money doesn't grow on trees. You're probably not so happy having to spend so much. So, we've created a completely free resource to help you learn. You can check out the link. These are video-based resources. Click on it for yourself to see if you like it. As long as you find the answers to the things that you're getting wrong early on, you're going to do well on the USMLE Step 1.

Step 3: Ramp Up

Let's fast-forward to step 3, the ramp up phase. This is 1-2 months before the exam. At this point, you have to think about your goals. First off, average USMLE scores are 229. Especially for international or foreign medical graduate students, if you're thinking [about entering a] competitive [specialty], you should be thinking around 265. Aim for that. If you are thinking about something less competitive, like pediatrics or family medicine, aim for 235. Figure out where you are on that spectrum of 235-265. What's your personal goal and what do you want to aim for?

You also want to set a time deadline. My best students are the ones who do. They know exactly the date they are taking the USMLE Step 1 and they really focus in on that rather than saying that they will take it when they're ready. Circle a date on the calendar and just move towards that date. And then you're a mental ninja. Get into the mindset of a mental ninja, with 10-12 hours of studying every single day. That means being disciplined with your social life, with eating, with healthy exercising, and with sleeping well, making everything in your day about preparation for that test.

Leading up to the test, figure out what resources you want to use and create a daily schedule. Osmosis allows you to do that very easily. You can type in when you want to start studying, how long you want to study for, and when your exam date is, and then check off the resources that you want to use. The popular ones include UFAPO, which is a fun acronym for UWorld, First Aid, Pathoma, and Osmosis. It automatically generates a day-to-day schedule for you. You can change the schedule based on how many days you want to allocate to each topic. You can also include breaks for yourself or assign yourself full-length exams on NBME or UWorld.

As you go through everything, remember that it's best to actively think rather than passively read or watch something. At this point, spend most of your time doing questions and then going back over your answers, because that's where you get a good sense of why you're getting things right or wrong. It also helps you get practice answering questions and builds endurance. Squeeze every bit of information or knowledge out of each question.

Here are some tricks on how to do that really well-the way I like to approach questions. First, cover up the answer options on a question and say, "What do I think the answer would be?" I don't allow myself to cue my answer by looking at something but just try to recall it. You can do that with your laptop screen by literally covering it up or not scrolling all the way down. After you've come up with an answer, verbalize why the right answer is the right answer. Put into words why the wrong answers are the wrong answers. Then, say what you would change about the question that would make one of the wrong answers correct. What would have to change? Really interrogate that question. Finally, say, "What didn't I get it right? What didn't I understand about the right answers or wrong answers?" And go look it up. Sometimes you will spend 10 minutes looking things up in those primary resources-the books, the flashcards, the videos-but it's well worth it.

Step 4: Crunch Time

Step 4 is crunch time. This is 1 week before the exam. You're still doing a lot of the same things, but in the final week, make sure to pack in information that is going to be heavy on memorization and light on concepts. These are things like biochemistry, microbiology (I'm an infectious disease doctor and I'll be the first to admit that microbiology is in this category), pharmacology, embryology, and genetics-stuff where you know there will be lots of questions. You don't want to get it wrong just because you didn't memorize some fact that you're supposed to remember. Spend that last week really focusing on this stuff. Make sure you nail all this stuff that's hard to keep straight. This is why you want to devote the last week to those topics. By this point, if you haven't already done it, finish off those NBME exams and make sure that you nail them-as many as you can. They're going to predict where your real score is going to end up. I've seen that time and time again. They're going to tell you what you can probably expect on exam day within 5-10 points.

Step 5: The Home Stretch

Now you're in the home stretch, step 5. It's the final day, 24 hours before the exam. On test day, you're not going to have anything with you-no books, no online resources, no flashcards. You're going to walk into the test by yourself. On the day before the test, I would suggest spending the day the same way. You studied hard. Just go and relax and get yourself in a good frame of mind. This is a day when you want to prepare for logistics, to make sure you know where to go and how to get there. Bring snacks for the day and sleep well the night before. Bring layered clothing, a light jacket in case it rains, and an umbrella. Make sure you don't drink too much coffee on the day of the test, because you are going to have adrenaline flowing; you don't want to be all shaky and jittery.

You want to pump yourself up, right? This is where confidence really matters. A couple of ways to do that are scientifically proven. We're going to go over them right now. First is power poses. This is where you just raise your arms. "Yes!" Really loud. "Yes!" You can do the double fist pump just like that. "Yeah! Yeah! Yeah! Pump it!" And then the other way is just forced laughter. Force yourself to laugh even if you don't feel like laughing. I hope you're laughing because otherwise I'd feel like a crazy person on YouTube laughing. By the end of it, you're going to start feeling really good.

Bonus Tips

I'm going to give you a couple of bonus tips. First, this is a marathon. Studying is hard. It's really tough, so get some software to block out websites that [distract you]. For me, that would be or social media. Just block that stuff out so you don't have to go to it. It's also good to divide up your work into 25-minute power sessions where you're working hard, and then 2 minutes to stretch out your back, stretch out your neck, and allow yourself to just breathe deeply and relax your mind.

I'm also an infectious disease doctor, so that part of me has to come through and say that in your final week, make sure you wash your hands. Make sure you don't stay around people who are sick. The last thing you want is to wake up on the day of the test sick and feeling terrible with a sore throat or something. If there's one thing to get out of this video, let it be this: Make sure you do little things to make yourself feel good. All of this is about taking care of patients eventually. This is just one hurdle you have crossed along the way. Keep that in mind, don't lose that perspective, and keep your spirits up by doing things that are good for you. So, go out. If it makes you happy, drink a smoothie. If it makes you happy, go to the garden. If you like animals, play with your dog. Do the things that make you happy. And on that note, I'm going to give you something that hopefully makes you happy. It's a little cartoon from Awkward Yeti. It always makes me smile, so enjoy the cartoon and I wish you the best of luck.


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