Step 101: Strategies and Techniques to Maximize Performance on USMLE Exams

By Andy Hiett

From the first day of medical school, students are constantly reminded of the profound impact board exam scores can have on their future specialty choice. The process of studying for boards can seem intimidating and overwhelming. These exams should be viewed as a manageable challenge and with the right strategies and techniques in place, this dr

• Language: English
• Publisher: Step 101 LLC
• Release date: Nov 9, 2023
• ISBN: 9798218293871

Book preview

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Overview of Studying for USMLE Exams

The Science of How We Learn

Arthur Ashe is a famous tennis player who once said, Success is a journey, not a destination. To me, this means that the daily grind and the desire to improve is what makes you successful, not the act of getting to the mountain top. Learning and academic success follow a similar principle. We often gauge learning on a short-term scale without consideration for how well we retain the information for when we need it later on. Getting an A in a class doesn’t define success. True learning involves making mistakes and figuring out how to adjust so you don’t make the same errors again. Success is learning the material well and repeatedly practicing it so that you can implement your knowledge in a real-life scenario to help a patient.

We have all grown up in a system that lauds high test scores, sometimes at the expense of long-term learning. We often lose sight of what is important and craft our study plans with the sole purpose of passing the exam. Student’s study plans typically consist of reviewing lectures, taking notes and then reviewing those notes over and over to cement the information into their brain. You can probably remember those days in college where you felt like you were pushing your brain to the limit, but can you actually remember the material you were studying? My guess is probably not. 

What if I told you that there was a scientifically proven method that would increase your chances of learning and retaining information? What if I told you that method deviated from methods that you’ve used in the past and would require a major paradigm shift to implement? Would you still be interested?

Scientists have studied how we learn and retain information and come up with a series of principles that have proven benefit. These principles, which are discussed below, are paraphrased from the book Make it Stick by Peter C. Brown, Henry L. Roediger III and Mark A. McDaniel⁴. Ideally, EVERY student would read Make it Stick before starting medical school. I highly encourage you to give it a few hours of your time, regardless of what stage of schooling you are at. I promise it will change the way you think about learning. Make it Stick sheds light on some of the common pitfalls with studying and provides advice on how to work smarter to learn more effectively. In the next section we will discuss some of the most salient points from the book to understand what really goes into learning.

When people reread their notes again and again or watch a lecture for the fourth time, they are engaging in something called massed practice. The thought with massed practice is that if you repeat the action enough times, you’ll develop muscle memory and never forget it, much like riding a bike. Riding a bike feels automatic for most of us and we don’t think twice about the underlying physics of the situation because it doesn’t seem relevant. What happens if all the sudden that bicycle gets swapped out for a unicycle? A unicycle is obviously much harder to ride and requires a more conscious, less automatic understanding of gravity, physics and balance. USMLE exams are the metaphorical unicycle. You’ll need to know the material well and be able to use that information to adapt to any situation. Simple muscle memory isn’t enough.

Research has been conducted to determine how beneficial massed practice is and the results are alarming to say the least. One study of college aged students showed that reading a text twice led to a slight improvement on a test taken immediately after reading compared to those who only read the topic once⁵. However, when a repeat test was administered later on, those who had reread the text did no better than those who hadn’t. Rereading works well in the short term but isn’t as beneficial long term. Studying for USMLE exams requires a long-term point of view in order to be successful. 

So, if massed practice doesn’t work well, what should I do?

In contrast to massed practice, spaced repetition involves repeated exposures to the material separated by time. Spaced repetition has also been well studied and the data show this technique is far more efficacious. One study by Kornell is particularly enlightening. He showed that when using flashcards, spaced repetition worked better for 90% of participants compared to massed practice⁶.

The most fascinating piece of the study is the fact that 72% of students felt like massed practice worked better. 72% of students thought massed practice worked better but the study showed 90% performed better using spaced repetition! This discrepancy is astounding and shows how poor we are at judging our own learning. So, before you think to yourself, Rereading and reviewing lectures works best for me, remember that there is empirical evidence that refutes this.

Another interesting component of the study deals with the idea of cramming. Flashcards that were studied the day before the exam were remembered better than flashcards studied two or three days prior to the exam. This means cramming works right? It works better than nothing but even the flashcards that were crammed were not retained as well as those that were studied using spaced repetition. In addition, holding a review session the day before the exam negated the benefits of cramming.  Students tend to have a difficult time letting go of cramming because they feel like they maximize their time by studying right up until the minute of the test. They feel like it has worked for them in the past. The problem is that students don’t notice the instances where it failed them. People anchor their perceptions to the times they reread a notecard right before a test and it helped them answer a question correctly. What about all the times you read a notecard right before the test and didn’t remember the necessary information?

Aside from how often you study, the manner in which you study is also important. There is a difference between recognition (familiarity) and understanding (fluency). Simply recognizing that high altitude causes metabolic acidosis doesn’t mean you understand it. The ability to see What kind of acid base disturbance does high altitude cause on the front of your notecard and think respiratory alkalosis with compensatory metabolic acidosis means you are familiar with that material. Fluency is seeing that same notecard and thinking high altitude has lower partial pressure of oxygen, which leads to elevated respiratory rate which leads to breathing off CO2 (respiratory alkalosis) acutely, which leads to eventual compensatory metabolic acidosis. The student who can practice studying by understanding the initial disturbance, compensatory changes and subsequent downstream effects is the student who is far more likely to correctly answer a USMLE question.

What is the best way to develop fluency?

The best way to develop fluency is through the process of elaboration. Take the information you have been presented, reorganize it until it makes sense to you, add some detail, draw connections to other previous knowledge and you will understand it on a much deeper level.  Allow yourself to ask Why? over and over again until you can explain a subject well enough to a classmate that they understand it. Then try explaining it to someone like your parents or siblings who isn’t in medicine. Can you make them understand it? Explaining the topic to someone outside of medicine forces you to consolidate your knowledge down into the most vital elements. You can’t go into the weeds when explaining cardiac electrophysiology to your sister so you will have to think about the big picture concepts. Thinking big picture allows you to form a framework for organizing the material and adding supplemental details⁷. Instead of rereading your notes from the previous day, write down everything you can recall from memory about the previous days lecture. Then, check your notes and you will have a much better picture of which concepts you retained and which ones you didn’t. If you are able to do this for most of the material you cover, there will be far fewer concepts that you truly have to memorize.

Another important concept from Make it Stick is the idea of interleaving practice. Interleaving practice means studying a variety of different topics or concepts together rather than studying one topic one day and another topic the next day. It also means varying the way in which you study the material. For example, reading from a textbook one day and doing practice questions over the topic the next as opposed to reading the textbook two days in a row.

Think back to some of your classes in high school or undergrad. Usually, you learn Concept #1 on day 1 and work practice problems covering concept #1 that night. On Day 2, you learn Concept #2 and work practice problems on Concept #2 that night. After a few iterations of this you take a test over the concepts. Usually, the exams are structured so that the first 5 questions would be problems examining your ability to implement Concept #1, the next 5 questions over Concept #2 and so on. If a test was constructed with the idea of interleaving practice in mind, the test might look like this:

Question 1: Concept #3

Question 2: Concept #1

Question 3: Concept #2

There is evidence showing that simply interleaving the question types on a quiz or test improved retention weeks later when the material was tested again⁸. Part of the reason for this involves how our brains process the information. When the concept or question is constantly different, our brain has to learn how pick up on clues that tell us if it’s one type of question or another. We are training our brain to recognize the difference between concepts and questions. This is vital for success on USMLE exams because the whole idea is being able to separate one pathology from another based on subtle differences. If we only work cardiology questions together and then move to pulmonology questions, we pay attention to how the questions are similar instead of how they are different. Elaboration and interleaving practice are important, but there is one additional piece of the puzzle that can maximize the effectiveness of your studying.

A sure-fire way to become more fluent is to test yourself frequently. Testing has several incredibly important beneficial effects. First, it improves retention of the material and reduces forgetting. Second, testing provides feedback on our understanding and calibrates our evaluation of our learning.

Multiple studies performed in classrooms show frequent quizzes increased performance on cumulative exams and this performance was maintained with tests at later dates⁹,¹⁰. The act of testing forces students to retrieve information they had previously learned. In addition, this retrieval is coming in a different form than how it was originally learned via lecture which is an example of interleaving practice.

Aside from improving overall performance, testing also gives the learner a better idea of their strengths and weaknesses. Multiple studies have demonstrated that students tend to perform worse on exams than they predicted¹¹,¹² which provides further support for the idea that we are poor judges of our own learning. We don’t even realize we have blind spots! Testing is a great antidote to this problem. Testing shows you empirically which topics you are doing well with and which you are struggling with. It makes you more aware and gives you the information you need to form a study plan specific to you.

It will take more effort to develop fluency than it will to develop familiarity and many feel that schedules that emphasize interleaving practice , spaced repetition and frequent testing are more difficult¹³. Despite feeling more difficult these methods have data supporting their efficacy. It’s like Tom Hanks said in A League of their Own, It’s supposed to be hard. If it wasn’t hard everyone would do it. The hard is what makes it great.

We covered some really important information so let’s summarize:

Massed practice leads to short term gains that disappear quickly. Spaced repetition works better for long term retention

Fluency > Familiarity and requires elaboration, spaced repetition, interleaving practice and testing to develop.

Testing can be a powerful tool for increasing performance and revealing strengths and weaknesses

How to Approach Studying

As you work through material in your first two years of medical school, you likely go from one organ system to the next in discrete modules. Some programs teach normal anatomy and physiology first and then circle back to teach pathology of those organ systems later on. Either way, schools tend to lump material into organ systems because it makes it easier to teach and allows students to focus on a narrow set of subjects. In practice, medicine requires much more integration to understand how certain organ systems are working together. Even highly specialized physicians such as a cardiac electrophysiologist must understand how a patients other comorbidities affect their heart. USMLE exams are similar as many questions require integration of information from multiple organ systems. Students need to practice this integration in order to score well and the earlier you start the better off you’ll be.

Think of learning and integrating the material like constructing a new house. Think of each individual room as a subject area (cardiology, pulmonology, endocrinology, etc.). Pretend the endocrine system represents your kitchen. Within the kitchen there are important features like a fridge, oven or cabinet.  (Diabetes, Pituitary Abnormalities, Thyroid abnormalities). Each of those appliances has to be organized properly. Fridges have drawers and compartments so that items can be properly separated and stored. The different types of Thyroid cancers make up one drawer of your refrigerator. The point of this whole discussion is that you need to have a clear way to organize the information to keep concepts separate.

The above analogy accounts for most of what is needed in a house but we forgot the most important piece: the plumbing, electricity and heating/cooling system. Without the basic infrastructure, the house is merely a structure without function. The plumbing, electricity and AC are what unites the house and ties all of the rooms of the house together. These systems are what make the house useful because I don’t know too many people who would live in a house without these features.

Understanding fundamental concepts or rules in medicine is like the innerworkings of a house. Homeostasis/negative feedback, inflammation/injury, and ischemia are concepts that show up over and over across all organ systems. If you understand these important concepts then you can extrapolate that knowledge to each of the individual organ systems.

Start by trying to understand the big picture concepts (homeostasis, ischemia etc.) during your first iteration through a given subject and as you continue to learn you can find examples of those principles in each organ system. As you work through the organ systems try to compartmentalize the information so that you have a framework to add detail to later. Test yourself by doing a handful of practice questions from a Qbank to figure out what subjects you understand well and where you still need some work. These early questions are key for accurately diagnosing your strengths and weaknesses. When you have accomplished these initial steps then you can start filling in the details with smaller pieces of information during your subsequent studies