To reach my current position as a general cardiologist, I have taken nine board exams. 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.
1. 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.
2. 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. 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 percent 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 percent 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 …”
3. 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.
4. More than 90 percent 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.
5. 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.
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. Textbook authors use scientific words and sophisticated vocabulary just like you will see on your exam. The best students I have advised over the years have been avid readers of textbooks in addition to the usual board prep materials.
6. 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.
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