How to Score Above 270 on USMLE Step 1

This blog post was published on June 6, 2019, and may include some outdated content. You may find some of these more recent posts on this subject interesting:

Preparing for the USMLE Step 1 as a Pass/Fail Exam

5 Biggest Mistakes Students Make While Studying for USMLE Step 1

How to Manage USMLE Step 1 Test Anxiety

Pathoma: USMLE Prep Platform Reviews

How I Scored 272 on USMLE Step 1

Having scored a 272 on Step 1 of the USMLE, I have often been asked “how in the world did you do THAT?!”. This post is an attempt to summarize what I believe were key steps in making that happen.

There are other resources and blog posts throughout our website that discuss how to organize your time effectively, such as our Free 5 Week USMLE Step 1 Study Schedule. This post is more a summary of my general approach to studying, processing, and internalizing the material as you go through it than a formally structured “how-to” guide.

Preparing for Step 1? Quiz Yourself as Much as Possible

My single biggest piece of advice is simple: quiz yourself as much as possible. Truly. Even find ways to quiz yourself on material as you’re reviewing it for the first time, e.g., when approaching a new table or page in First Aid, cover up the table and ask yourself what you think belongs in each row and column. The first time you do this, you’re liable to know little to no of the information within the table, but by posing each item in the table to yourself in the form of a question as opposed to another statement to be read, you increase the salience of your lack of knowledge of the contents of the items in the table, and the information it contains is that much more likely to stick. Then, when you approach that information again 10 minutes, 2 hours, 2 days, or 2 weeks later and attempt to review or re-learn it, the neural pathways that you previously engaged in quizzing yourself the first time comes back on-line and is reinforced as you attempt to recall the same information again.

Use Active Learning Techniques

Indeed, the evidence regarding adult learning theory suggests that this sort of active learning is key to promoting understanding and retention. What creates active learning? Forced recall and integration of concepts across multiple areas. By forcing yourself to attempt to fill in information rather than reading it passively, you engage your brain in an active, memorable process of identifying what you do and do not know, thereby creating “holes” in your headspace into which you can insert the relevant material with a greater probability that it will have a place to stay around, rather than just reading, taking notes, highlighting, and hoping facts will stay in your mind.

USMLE Step 1 Study Plan and Strategy

Specific strategies I used for incorporating active learning into my exam prep was as follows:

-Keep a small piece of paper with you at all times to cover up any tables/charts in First Aid and in UWorld and move it down line by line to force yourself to attempt to come up with the contents before looking at the chart

-Whenever you have an “aha” moment or come across a key point that differentiates 2 disease processes (e.g., elevated methylmalonic acid and homocysteine in B12 deficiency vs elevated homocysteine alone in folate deficiency), create a flashcard to help internalize that high-yield differentiating point. Flashcard apps that incorporate spaced repetition into their user interface (e.g., Anki) are particularly useful for your USMLE prep. Nail this technique with 6 easy tips. 

-Instead of passively reading over incorrect answer choices when reviewing UWorld blocks, force yourself to ask yourself why each of the wrong answers is wrong, and only then compare your best guess with the explanation provided. In general, the more mentally taxing something is, the more frustrating it is to study, but the more likely you are to retain it. Again, intentional practice in this way increases the salience of the explanation by forcing you to commit to an explanation prior to reading the information.

-Whenever you see a topic or pathway that comes up across multiple UWorld questions and really just requires rote memorization (e.g., biochem, pharmacology, micro: steps in heme synthesis, side effects of lipid lowering therapy or antiarrhythmics, bacterial toxins, etc.) force yourself to write down as much of the relevant knowledge as you can from memory, including integrating related concepts from other topics.  For example:

          -writing out each step in heme synthesis with the blockades associated with each disease, and understanding where B6 deficiency              comes into play

          -writing out each anti-lipid or anti-arrhythmic drug’s mechanism of action, effects, and side effects,

           -writing out the mechanism of action of each toxin with the bacteria it’s associated with and the gram stain and other bacterial identifiers.

-As you rehearse doing the above from memory over and over, they will eventually become second nature and you’ll be able to apply them even in the high-stress environment of the exam.

The USMLE loves to ask “two-step” questions like the examples listed above.  So, the more you practice connecting the dots from one chapter to another within FA, the easier it will be to make the connections expected of you by the NBME on exam day.

Each of these strategies appeals more or less to certain individuals, but I found that the underlying principles of forced recall and interleaved practice were extremely effective for me.

Some other general test prep advice is as follows:

• “Know thyself.” Know what you do and do not know going into your dedicated study time –
  • Personally I knew the biochem, micro, immunology, anatomy, and embryology were (a) not taught in a high-yield manner for Step 1 at my school and (b) much farther from me in chronologic terms (i.e., learning Micro for the first time in October ’14 and taking the exam in February ’17.) Once you know what you’re weak on (either from preliminary QBank results or just your own intuition), don’t feel chained to the notion that you have to “get through” everything in equal proportions, but instead repeat the subjects you’re unfamiliar with early and often throughout your studying period.

• Regarding efficiency, I would say the most important thing is to focus on actually learning from a resource rather than just trying to force yourself to get through it to feel like you’ve accomplished your study task for the day. I always pushed back plans for how much I would cover when I knew I couldn’t cover it all and actually understand and retain the material.

• Do not fall into the trap of buying more and more materials just to say you made it through them all – it would serve you much better to know UW, FA, and Pathoma cold than to “just get through” Kaplan, UW, FA, Pathoma, Sketchy Micro, Picmonic, BRS Physiology, etc. etc.

• When you are reading questions, try to ask yourself “what unambiguous entity is this question trying to get me to identify?” Remember, for whatever question you’re posed on exam day, the answer must be universally agreed upon by a panel of experts (unlike many med school exams that are written somewhat more arbitrarily and may trick you up).
  • So, particularly for the questions that are more than just rote memory (what cell secretes IFN-gamma?) try to look for patterns instead of taking each detail as a separate data point. For instance, when you hear diabetes, HTN, HLD, and smoking, you should be thinking “what are they about to ask me about atherosclerotic vascular disease, from CAD to cerebrovascular disease to mesenteric ischemia to peripheral vascular disease to renovascular hypertension 2/2 bilateral renal artery stenosis?” before even looking at the answer choices.
  • Similarly, when reading a stem on, say, cirrhosis, you should start to bring to mind all the etiologies you can think of (alcohol, hepatitis B and C, autoimmune hepatitis, Wilson’s disease, A1AT deficiency, hemochromatosis) and begin thinking of how examiners could unambiguously identify one of these for you – neuropsychiatric manifestations with Kayser-Fleischer rings for Wilson’s, early-onset emphysema for A1AT, bronze diabetes, cardiomyopathy, and arthralgias for hemochromatosis, Wernicke-Korsakoff, aspiration pneumonia, and macrocytic anemia for EtOH, and history of immigration from an endemic region vs. IV drug use for Hepatitis B or C…and THEN you should start thinking about how you could test for each of those things, AND the underlying pathophysiology of each.

• The key is making connections as often as possible so that each question becomes a mini-review of every possible topic. Once these webs start to interconnect in your brain, “retention” will become less rote and more facile because your brain remembers why one factoid is relevant in distinguishing one disease entity from another and in allowing you to corral your knowledge base into more organized chunks.

Step 1 Study Schedule

On another note, the dedicated study time you have to review for Step 1 is an important time to re-learn and reinforce high-yield concepts. It is impossible to do really well on the USMLE without building a strong knowledge base from the beginnings of your medical education, as you only have 2-3 days for each topic in turn to review the high points.

My medical school, like many others moved to a pass/fail system for the preclinical years, which was great in terms of reducing stress and increasing collaboration among pre-clinical students. If you also attend such a school, then use the increased flexibility afforded by that grading system to “pass” rather than “ace” your exams.  Take a step back when going through each block to ensure you are keeping up with the highest yield material from each section as outlined in First Aid as opposed to whatever minutiae are emphasized by your school’s department of biochemistry, immunology, pathology, etc. This advice is particularly relevant if your school has a pre-clinical curriculum that is not specifically tailored with Step 1 in mind, as was the case for my school.

Taking care of yourself — Wellness

Finally, a note on wellness: I took 45 minutes to 1.5 hours every day during my dedicated study time to exercise, stretch, do yoga, take a walk outside, call a friend, whatever…I think I would have burned out and done more poorly if I hadn’t made that a priority, even on the days I hadn’t done as much (UW, FA, etc.) as I had hoped. As a future physician, you must learn to take care of yourself so that you can take care of others, and your USMLE prep is no different.

Not every medical student needs a USMLE tutor. However, tutoring is highly recommended to score high or improve your score in many situations. Learn when an experienced USMLE Step 1 Tutor can help you reach your score.