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Lauryn Falcone, MD, PhD and Shelby Wood contributed to this post.

From the day most students start medical school, they learn about the USMLE Step 1 exam. As the months go on, talk of the exam becomes an almost daily occurrence. It’s not surprising, then, that many students feel they need to devote as much time and energy to preparing for this exam as possible.

For some, this manifests as weekly USMLE practice questions and frequent skimming of review books as early as first year. Others may spend their entire first summer preparing for Step 1. Some students sacrifice Thanksgiving, Christmas, and spring breaks to prepare. On the contrary, other students do little prep before their dedicated Step 1 study period.

So, the question remains: what do you need to know about getting a head start on USMLE Step 1 exam prep?

The following offers some myths and truths to guide you through the process.


MYTH: Excessive, early worry about the USMLE Step 1 will lead to a higher score. Students with higher test-taking anxiety generally score lower on the USMLE Step 1. A recent study found that greater test-taking anxiety was associated with lower USMLE Step 1 scores (1). Students with less anxiety about testing generally achieve higher test scores.

USMLE Step 1 is a high stakes exam, so it is natural that students’ will have a lot of apprehension about this exam. However, worrying about this exam days, months, weeks, or even years in advance may do more harm than good. Students who are months out from the exam should try to focus on their current coursework material rather than stress about Step 1.

For students who have trouble quelling their USMLE fears, at the very least, it is important to develop the mental strength to put test-taking fears aside on test day. As a competitive runner, I often use my experiences racing as a metaphor for life’s challenges. I remind students that it’s ok to be nervous before the race, but when the gun goes off, it’s time to perform. Stand on that starting line calm and confident, knowing you prepared to the best of your ability and be excited to showcase your hard work and talent.


MYTH: The longer you study for Step 1 the better. As a tutor, one of the biggest challenges I face is convincing students that they are ready to sit for the Step 1 exam.

All too often, students want to push their exam as late as possible to give them a few more days or weeks to study. Most students feel that more time will give them greater ability to retain more knowledge and potentially earn a higher score. But the reality is that students who push their exam to the very last minute or even delay the next step of their training to allow more time to prepare are typically not the students achieving the highest Step 1 scores.

Numerous studies have indicated that increasing the number of days studied does not lead to increased Step 1 scores (2). In fact, Kumar et al. found that students who studied over 40 days in their dedicated Step 1 study period achieved higher scores than students preparing longer than 40 days (3). With that said, this doesn’t mean preparing early for Step 1 can be a waste. Rather, it suggests that quality is more important than quantity. Which leads us to our next point . . .

When should I start studying for USMLE Step 1? 

Most students begin incorporating Step 1 review content into their final semester of basic sciences, but you can really look at all of your second year as a slow buildup to the Step 1 exam.

Focus on keeping a steady pace so that you don’t burn out too quickly—as cliche as it sounds, Step 1 prep is a marathon, not a sprint.

Once the final preclinical year of medical school comes to a close, most students will begin their “dedicated” Step 1 prep period (often simply called “dedicated” for short), which typically lasts 5-8 weeks during the summer between the end of second year and the beginning of third year clinicals. Some students take more time than this, and others take less. You will find your own “sweet spot” when it comes to the length of your dedicated period.

 

MYTH: It's ok to sacrifice preclinical coursework studying in favor of early rigorous Step 1 prep. It is extremely important for students to learn their coursework material well the first time around. I always tell students that while they are still taking classes and studying for exams prior to their dedicated Step 1 study period, they must make their coursework a priority. Only after they are doing well with their coursework and managing time appropriately can they start to incorporate Step 1 prep. This means that if you are really struggling with a particular subject, it is important to get help. Talk to your professors. Get a tutor. Learn the material well the first time. And, most importantly, don’t sacrifice your coursework material in exchange for spending more time on early Step 1 prep. It is important to have a solid basic medical knowledge before one can expect to do well on Step 1. Qbanks and review books are designed to be just that—review sources for material you have already learned.

 

MYTH: Using as many resources as possible will lead to a better Step 1 score. With the ever-expanding abundance of supplemental study resources available to medical students, from Pathoma, to Sketchy, to Boards & Beyond, it’s no wonder that so many students believe that they need to use every single one of them to do well in medical school and on Step 1.

While these resources can certainly play a role in your studies, they are not all essential to your success. In fact, using too many of these resources is often so overwhelming to students that they spend too much time trying to plow through videos or book chapters, memorizing facts from each separate resource rather than synthesizing information into a deeper understanding of the material.

Different resources may come in handy at different points in your medical training (i.e. Pathoma during pathology blocks, Sketchy during microbiology, etc.), but I typically recommend that students use a maximum of 2-3 supplemental study resources during their dedicated Step 1 prep period so as not to overwhelm themselves and to enable them to focus on the most important study tool of all: the qbank.

 

TRUTH: Completing more practice questions correlates with higher USMLE Step 1 scores. Learning how to dissect Step 1 questions is key to getting a high score, and there is no better way to learn than by completing many practice questions. Research supports the notion that completion of more practice questions correlates with higher Step 1 scores (3, 4). We retain so much more information from active learning rather than passive learning (reading books, watching videos) because it takes an extra mental effort to pull the information needed to answer a question from the deep recesses of your brain, and that skill of “memory recall” is the key to a high score on any major exam.

When I work with students, I challenge them to always question why they missed a question. Knowledge gap? Fell for a distractor? Read the question wrong? Students who complete more practice questions not only review a greater diversity of material but also learn more about themselves and how to better tackle challenging Step 1 questions.

 

TRUTH: There is no “one-size-fits-all” approach to preparing for the USMLE Step 1. If you speak to some of your classmates during their dedicated Step 1 prep period, you may hear a variety of different strategies and study schedules based on that individual’s personal preferences.

For example, one student may prefer to wake up at 4am, go for a one hour run, shower, eat breakfast, and then grind through questions for the next eight hours, ending her day early around 4pm. Another student may wake up at 10am and hit the books for 12 hours straight, alternating UWorld blocks with reading chapters of First Aid and watching Pathoma videos, ending his day around midnight. Both of these students probably believe that their approach to Step 1 studying is the “correct” one, but there is truthfully no one “correct” way to study for Step 1—otherwise, everyone would be doing it!

Dedicated Step 1 prep is a time that you need to tune out the rest of the world and ignore what your classmates are doing. Just because a particular method works for one student doesn’t mean that it will work for you, and it certainly doesn’t make your alternate method “incorrect.” This is your time to shine and grind it out YOUR way!

 

In summary, the decision on when to begin Step 1 preparation ultimately depends on a number of factors. For students looking to get a head start prior to their dedicated Step study period, I encourage the use of a qbank to review questions on material they have already covered or are currently learning in their medical school classes. It is best to set a goal of completing a manageable number of practice questions each day so as to complement, rather than hinder, coursework studying. It is also key to remember that quality of studying is better than quantity, and that studying for this exam is a unique experience for each individual medical student.

Lastly, and perhaps most importantly, students should focus on finding healthy outlets for managing anxiety and stress and not let it consume them on test day.

 
References:

1. Green M, Angoff N, Encandela J. Test anxiety and United States Medical Licensing Examination scores. The clinical teacher. 2016;13(2):142-6.

2. Giordano C, Hutchinson D, Peppler R. A Predictive Model for USMLE Step 1 Scores. Cureus. 2016;8(9):e769.

3. Kumar AD, Shah MK, Maley JH, Evron J, Gyftopoulos A, Miller C. Preparing to take the USMLE Step 1: a survey on medical students' self-reported study habits. Postgraduate medical journal. 2015;91(1075):257-61.

4. Burk-Rafel J, Santen SA, Purkiss J. Study Behaviors and USMLE Step 1 Performance: Implications of a Student Self-Directed Parallel Curriculum. Academic medicine : journal of the Association of American Medical Colleges. 2017;92(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 56th Annual Research in Medical Education Sessions):S67-s74.

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