How to Study for the USMLE Step 1

I’ve spent the majority of my “adult” life as a standardized test taker. As a resident physician, my skills are still developing. But as a student, as an aficionado of the multiple choice question, I’ve already reached (and probably lost) my peak abilities.

I am asked frequently about my thoughts on the Step exams, especially the USMLE Step 1. It is after all the single most important determining factor in what specialty a medical student can reasonably hope to enter and probably the easiest and most-used exclusion criteria used by program directors everywhere (with the likely addition of graduating year and US Allopathic schooling). I can hear your thoughts. They ask, how should I prepare? My answer is simple:

USMLE World.

Theoretically, any good question bank should do. In practice, UW is the best.

More so than First Aid, more so than Goljan, and absolutely more so than Doctors in Training, I believe the USMLE World question bank is far and away the most critical component of Step preparation (with a solid helping of Wikipedia). Here is why:

When you learn a fact in a book, you can congratulate yourself on adding a virtual index card into the Rolodex of your brain. However, you have not indexed this fact in a retrievable way. It isn’t necessary usable in a test-taking context. This is one of two reasons why many people who know things still do poorly on tests. They can talk about it, but they can’t apply it. You may know the right buzzwords but never seen them described in an exam question. When you do questions, you both learn facts and learn them in context. You learn them in a question format, instead of learning them in a paragraph and then struggling to integrate and apply it to a question. Your time is valuable, wouldn’t you rather kill two birds with one stone?

UW questions have extensive explanations and are essentially a textbook page unto themselves. You can learn what you need to know from UW. The only downside to UW is that is not “organized” like a book for those students without sufficient background in need of a stronger foundation (this is what a quick read-through of First Aid as fast as possible at the very beginning of your study process will give you: a reminder of what you’ve learned, a horrifying glimpse of how much you do not know). This can be is a strength for two reasons: 1) it’s [slightly] less boring 2) the USMLE is not divided into sections. You never know on what topic the next question will be. 3) Patchy random exposure to topics isn’t exactly “spaced repetition,” but it does work along those lines.

So read through First Aid in a week or less. Just get through it. Bring up all the hidden junk you memorized long ago, then go straight to questions. Questions, questions, questions. Use books only to memorize tables and diagrams or flesh out your knowledge when you find yourself stumped by concepts or totally out of your element. Many students spread themselves thin trying to get through multiple sources at the expense of not doing enough questions—this is a mistake. Focus and depth trump breadth, end stop. Go through UW and mark/flag all the questions you get wrong and all the questions you guess on. Then do the marked ones a second time. Unless you have a significant problem finishing exams on time, I believe in “tutor” mode: this mode allows you to learn the correct answer and read the explanation immediately after each question. The goal is here is to learn first (and simulate the test second). If you do NBME practice tests closer to test day, those will obviously be done in timed mode. Ultimately, this is a matter of preference.

UW also goes to the trouble of explaining not only why the right answer is right but also why the wrong answers are wrong. This is crucial. This means you learn how to answer similar questions correctly again as well as when the wrong choices would be correct. Several related facts in one caffeine-riddled swoop. These explanations are on the whole excellent. These exams no longer include the classic buzzwords found in review books; they describe those buzzwords and key phrases. UW employs this nuance well.

The second major reason people struggle with MCQ tests is the inability to “get in the head” of the question writer. There are individuals who seem to test better than they should. You could ask them to explain why they choose the correct answer and they typically cannot explain themselves. Or, if they know why, it often is not entirely based on their book-knowledge. They’re able to narrow it down to those same two choices as the next guy, but they pick the right one more regularly. These people are natural test-takers. Step 1 is a MCQ test, but its style is not identical to that of the SAT or MCAT. You need to do Step questions to know how to do Step questions. It’s like any other skill. Hone it.

Because you wouldn’t learn to play guitar by practicing the flute, would you? Sure, the flute is a musical instrument: your dexterity would improve, your knowledge of tempo, rhythm, and music itself would develop. But if you picked up a guitar, you would still suck. Don’t spend 10 hours a day for six weeks learning the flute, then pick up a guitar and hammer on a few chords for a week and call yourself a guitarist. Just play the damn guitar. Skip the middle man.

Here is my compilation of free USMLE questions, which can be helpful before you’re ready to shell out for a definitive resource. Here are some things to keep in mind while studying. And some more thoughts about how I read Step questions.


Dustin 02.13.20 Reply

Hi Dr. White,

I am a new fan of yours after listening to the White Coat Investor Podcast episode you were recently on. Fantastic information! I also look forward to reading your books.

I tried reading through and word-searching the comments to see if my question had been asked, I apologize if I missed it and am re-asking the same question as someone else. I am currently preparing for step 1 and started with a very low baseline score on my first NBME practice exam. Recently I took my third practice NBME and have still only achieved a 189… I have improved all three times but obviously have not broken the passing score of 194 which has been discouraging. I’m sure people will wonder why I am being so open about my low scores. I try to be an open book so I can receive open and honest feedback.

In my attempt to simplify my preparation I am using sketchy micro/pharm (30 mins. to one hour review/day), UWorld (approx. 80 questions/day), anki (making cards for the questions I’ve missed and the one’s I answered correctly for the wrong reasons), and referencing FA briefly if needed. Finally my question. Do you consider making anki cards as a part of my review a worthwhile use of my time? I have used anki in the past (a mix of my own decks and premade decks) and the repetition has been helpful. But I feel as if I’m taking too much time to make a card and then more time reviewing the cards due each day. I know some people are anki worshipers, and some hate it. I’m more of a in-the-middle kind of guy. I know everyone is different, so there may not be a cookie-cutter answer. If you have any advice for being more efficient in using anki/flashcard making for UWorld, or cutting the cards out of my studies to review questions in a better way I’m all ears! Hopefully my question makes sense! And hopefully I didn’t make too many grammatical errors. :) Thank you for all you’re doing.



Ben 02.13.20 Reply

Definitely a personal choice. Spaced repetition is a great learning strategy, but even doing questions themselves in high volumes automatically has a component of that (for the high yield topics needed to pass). If I were in dedicated I’d probably forgo making flashcards personally. If I did, perhaps only the “take-home point” and nothing too exhaustive. Just enough to keep the highest yield stuff fresh.

At the score you’re at, you’re going to get the most bang for your buck by really mastering the important high-yield common stuff and not so much the esoterica. When your performance is low, I think it’s helpful to really focus on the most direct forms of study. The most direct way to prepare for a MCQ test is to take MCQ tests. But the real answer does depend on why you’re getting questions wrong: is it that you’re not linking up your knowledge to being able to answer questions? Or are you missing big parts of foundational facts (which you could hammer home efficiently with Anki)?

Phil 02.13.20

By the way, did you guys hear about Step 1 becoming pass/fail recently? Any thoughts what that will mean for MD’s or DO’s?

I’m hearing from classmates that this just means Step 2 will be the new Step 1. Except we’ll only have one chance to do well with Step, unlike before, where if we didn’t do as well on Step 1, we’d have another chance with Step 2 to make up for it. Also maybe this means residencies will have to prioritize other things like research. I just can’t see how this is a good thing, but maybe I’m missing something!

Dustin 02.16.20

Great thank you. And I think the reason i’m getting questions wrong is 30% knowledge gaps, and 70% applying the knowledge to the questions. As I do more and more questions I do notice that I’m able to recognize how certain things are being presented. So hopefully I can bridge that gap as I do more questions. And with the questions I miss I’ll take your recommendation and make a “take-home point” note rather than spending lots of time trying to learn it in a better way. Thank you!

Ben 02.14.20 Reply

I have lots of thoughts but I largely agree with Dr. Carmody’s here:

This will be a period of change, and it may even be a rough transition. I know in this post-fact world we live in that people are cynical and want to cling to an objective measure. Students know what to expect. For those who put the time in and succeed, doors can be reliably opened. Everyone’s concerns are valid. A better future isn’t even guaranteed, and Step 2 CK will be the new default if it’s allowed to be. Even that isn’t a totally bad thing; it’s a better test.

But Step 1 is not good measure. It’s turned medical school into an overpriced correspondence course and forced students to waste all of their energies spending more and more time mastering less and less useful material. Schools and residency programs have a couple years to figure a more meaningful way to evaluate students and select residents. Pass/fail Step 1 is a lit fire under everyone’s tushes. It’s not a solution, it’s a first step.

Mohamed Abdulla 06.03.20 Reply

Hi ben.

Hope your well.

I would like to obtain the usmle sapphire and usmlequickprep qbanks.

Can you help….there is an incentive for you

Ben 06.03.20 Reply

No, I cannot help you.

PN 02.26.21 Reply

Hello Dr White! Thank you for such an informative website, it’s truly so helpful! I was hoping you could give me some advice on how to approach reviewing UWorld questions. I have already watched the BnB videos, annotated my FA and have done 60% of uworld. However I feel as though I’m not retaining the information and I keep getting questions wrong on concepts that a few months back I was confident in. I end up taking +4 hours reviewing 1 block (i do tutor mode) and its making me more anxious that I am taking this long and then still not retaining the information. I don’t know what to do or how to efficiently use uworld and maximize my use of the question bank. Could you please give me some feedback on this and how I could change my approach and study methods with uworld. Thank you for your time!

Ben 02.27.21 Reply

I don’t know from your description, but one thing to make sure is that your spacing between topics isn’t too long. Spaced repetition is based on the forgetting curve. Stack the same material too close together, and it’s too easy/not efficient. Too long, and the material is almost new again. Some folks will try to cluster their learning so that they do, say, biochemistry or cardiology all at once and then move on to something else, leaving periods of months between reviewing the material. That’s probably too long.

PN 02.27.21 Reply

Thank you for the reply Dr. white, I really appreciate it. The way I do uworld blocks is random and tutor. I then read the explanation and the wrongs, then I would go to my FA and read that topic and jot down a few notes if I didnt know the fact or concept. But I feel as though I am wasting time and taking too long as well as not being able to retain the information. Im not sure how to improve this issue or if I’m getting too caught up in the details of the concept and then panicking at how much time I have just spent and then not retained the information. I dont know how to improve my approach and how to efficiently use uworld and be able to review in a more effective manner. Thank you for your time and advice!

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