Learning Medicine

Learning Medicine
The Ultimate Guide to Study Skills in Medical School

Friday, August 24, 2012

Day 0: Step 1 Preparation

Welcome to my Step 1 Preparation Series. Over the next few weeks, I plan to blog about my preparation for Step 1. My purpose is to record and reflect on my experiences in the hope that they will help others in their own Step 1 journey. I also plan to share insights about what goes well and what doesn't. And, I plan to create and share resources for Step 1 studying, such as videocasts on high-yield topics, my Anki cards, and whatever notes I put together. I truly hope that visitors to this blog find it useful and informative, and that everything I write is read with a critical eye.

So now that the clinical year here at Duke is over, there's one big hurdle I have to jump over before I go to grad school - Step 1. As most medical students well know, this exam, for good or bad, has a huge impact on what our residency prospects are, and so it has to be taken seriously.

Because of the gravity of this exam, like many med students, I've directed my efforts at preparing for Step since early in first year. To be sure, I've focused on learning medicine, period. But at the same time, I've made it a point to cover the things that are tested on Step.

Over the last two years, I've been conducting a personal experiment in learning. As I've written about so many times before, I've been using a digital flashcard program called Anki that is based on a learning principle called spaced repetition. Nothing else I've ever done has had such an impact on how I learn. Now, rather than briefly learning things just to binge, purge and forget on tests, I can now reliably retain the heaps of information I'm exposed to in medical school. 

When I first adopted Anki for med school back in the beginning of first year, I had a couple of goals. First and foremost, I wanted to make permanent the learning I was going to do in the classroom. I thought it an absurd notion that we were supposed to put so much effort into learning fundamental knowledge and then promptly forget the majority of it. What a waste of time and effort! So my goal was to keep the basics in my head for my future career as physician. Another important goal was for Step 1 preparation. The traditional way to treat Step 1 is to go through the preclinical years, binge and purge. Try to remember what you can, but do so in recognition that most of what you learned is going to have to be relearned before taking Step 1. Annotate First Aid with class notes. Then, take 4-6 weeks to do a huge review of all the material, plowing through First Aid and other review books. Then do 2000+ USMLE World questions. No doubt that works well for many people, but I think it is suboptimal for a couple of reasons.

(1) Stress: Trying to review so much information in so little time is highly stress-provoking. As you see all the information you've forgotten and envision all the information you need to now relearn, you bear a huge psychic cost. Plus, there are just limits as to how much the human brain can absorb in a limited amount of time.

(2) Long-term knowledge: With such rapid review, it is unlikely that the fruits of that labor will be preserved for long. What I mean is, since cramming doesn't lead to much long term knowledge retention, all the stuff people learn for Step 1 is lost shortly after taking the test. For some, that's a necessary evil of the game. And they don't mind forgetting Step 1 stuff, since many believe it's not clinically relevant. I don't deny that - some of the stuff is low-yield for life. But a lot of it isn't, and is worth remembering. So why spend so much time trying to learn but then forget?

(3) Performance: This is the most important factor. It makes sense to me that if one has a really solid base of medical knowledge that has been worked into long-term memory through continuous study that he would perform much better on Step. There would be less stress, more confidence, and a better score.

My Approach

So, I've decided to take an experimental approach. Most Step 1 study strategies have two basic elements: content review and practice questions.

My approach has been to spread out the content review over the last two years through my daily Anki reviews.  With only a couple of lapses (my honeymoon being a necessary and welcome one!), I've stuck to a review schedule on Anki nearly every day since first year. I've been studying continually, seeing material from the classroom years every day.

By this point, I feel that I've developed a really solid foundation of Step 1 knowledge that is burned deep into my brain. I feel confident and comfortable with the material. My Step 1 prep in the next 7 weeks will consist of only very minimal content review.

The majority of my time will be doing practice questions from USMLE World and USMLERx. Most people agree that doing questions is an incredibly useful and effective way of preparing for Step 1 because it forces integration and application of all that knowledge. Step 1 questions require "two-step" thinking, and that can't be learned just from remembering facts from Anki.

So because I've done most of the content review already, I'm going to weight my preparation heavily on doing practice questions, with the goal of getting through both qbanks by the time I take my test on October 18.

The Next 7 Weeks

I've decided to treat my Step 1 prep not merely as a way to get ready for a test, but as a time in which to take a broad view of all the knowledge I've amassed in the last two years, fill in the blanks, and synthesize a complete picture of the basic science groundings of medicine. In this light, the next few weeks should be actually... enjoyable. I think attitude counts for a lot, and if I were to be dreading the work I need to do, it would be miserable and not very effective. So I'm keeping my head up and trying to take the long view - what I'm about to do isn't just about a test, but it's about solidifying the knowledge I'll make use of as a physician-scientist.

More importantly, this time is the culmination of a two year personal experiment with spaced repetition. Now is the time to see whether or not the efforts I've put in with Anki will bear fruit, to test my hypothesis that a spaced repetition system would give me durable and retrievable knowledge. Just from my experience this past year on the wards, and in some of my preliminary Step assessments, I think I can say that Anki indeed does work, and it works very well. I'm more excited about the method than the actual particulars of Step studying. The implications are huge... here now is a system that I (and anybody else) can use to remember critical information for the long term. No longer do we have to just spend time, money and effort to "learn" and then in short time, have very little left in our brains to reflect those efforts.

OK, so what am I actually going to do. Here is a synopsis and my calendar:

Aug 27 - Sept 11: Content Review/Selected qbank questions
Topics covered: Biochemistry, Gross Anatomy, Embryology, Selected topics in physiology, pharmacology and gross anatomy. Also, one very quick First Aid 2012 overpass to glean any facts that I don't already have in my decks. One very quick pass over Pathoma videos too.

I'm doing this because there were parts of my school's curriculum which were either very weak or nonexistent, and occurred before I knew about Anki and about bucking the curriculum in general and doing my own thing. So I'm going to have to go back and do some review. In the ideal scenario, I wouldn't do any, but this is the reality. Plus, like I said, I want to use this time to fill in holes, and some topics I really want to learn at a deeper level for my personal interests, in particular cardiac/respiratory physiology and some gross anatomy.

Sources: First Aid 2012, Pathoma, Lippincott's Biochemistry, Boron and Boulpaep's Medical Physiology, Big Picture: Gross Anatomy.

Qbanks: USMLERx.

Sept 11-Oct 16: USMLERx/USMLEWorld qbanks, everyday, all the time, straight crushing. 

This is the heavy lifting here. Qbank questions are extremely useful - necessary in fact. This is a way to bring together the disparate facts and apply them to the real task of Step 1.

What I've Done Already

So I want to be clear about what I've already done because I want to give an accurate representation of what my studying has consisted of up until this point. This is important, because if anyone is going to use my resources or follow my study method in the future, they need to know what I've actually done.

USMLEWorld: I've been through this qbank 1x already. I did it casually from December 2011-Feb 2012. I used the explanations to make Anki cards for things I didn't already have curated in my decks. I did questions selectively, but got through the whole bank. My average was about 70-75% overall. I haven't touched these questions since February, so I don't think I'll be able to recall answers just from straight memorization. That's why I did the qbank a few months in advance.

Clinical Year: This is a big one. My school has us do clinical year in our 2nd year. So I've been on the wards
for a little more than 12 months, and so I've been continually exposed to medical knowledge, some of which overlaps with Step 1 material no doubt. Also, during the year, I've done some reading on pre-clinical topics whenever I had a free moment. I know most readers of this blog will not have had clinical year before taking Step. That's fine. I think it's somewhat helpful to have seen diseases in real life... it makes diagnosis that much easier. But clearly it's not a necessity to have been on the wards to crush Step 1.

Anki: Oh Anki. How I love you so. And how much time have we spent together?

Here is the breakdown*
This is not including every deck I've done. I threw out some too. But these are the ones I've kept and do continually to this day.

Deck  (as of 8/25/12)

Pathology: 507.3 hours
Physiology: 76.9 hours
Pharmacology: 132.2 hours
Microbiology: 82.1 hours
Immunology: 22.5 hours
Gross anatomy: 35.5 hours
Neurology: 35.8 hours
Biochemistry: 10.2 hours

That's a lot of hours! That, of course, doesn't include the hours spent doing the primary learning. That probably numbers into the thousands. But who's counting.


This is a great resource. I started checking it out in August of last year and used it casually throughout the year. I watched the videos and made cards for the Female Reproductive and Heme-Onc chapters. I'm going to blast through the whole video series at 1.7x starting next week.

Assessments and Progress

The first thing I did last Thursday was to take NBME 11 and USMLE World Self Assessment 1 to see where I'm at before I start this whole process. My goals were to identify areas of weakness and strength, to give me a fairly realistic picture of how well I'm doing now and how hard I'll need to study to perform at a high level on the real deal.

I've compiled the results of those tests in a Google Doc that I'm going to use to chart my progress throughout my studies. I want to share that progress, but I'm hesitant because I'm not exactly anonymous and I don't know if it's a great idea to post scores on the web. Tell me if I'm wrong here. Perhaps when all this is over, I'll make it all public so people can really scrutinize my recommendations and see if my non-traditional strategy is worth a shot.

I don't mind remarking in a qualitative way on how I did, however.

NBME 11: rocked it. very surprised and happy with how I'm doing at this point.
Areas of weakness: biochemistry, biostats, embryology. Not a surprise since these are the things I haven't studied seriously yet. Overall, the test seemed really simple to me. Almost too much so. I've heard NBME forms 11-13 are the most realistic, with 13 being the most true-to-life. I'll save that one for the end.

UWSA 1: rocked it too. Even more so than NBME 11. But I've heard the curve is quite generous so I can't be too certain as to the accuracy of their prediction. nevertheless, it was a boost. I thought the questions were slightly harder and more nit-picky than NBME 11. Not a bad resource though. I've still got UWSA 2 left.

Going Forward

All right. I've written enough for this post. I'll begin my studies on Monday and I welcome everyone to follow my progress. As I said above, I plan to share little nuggets, high-yield videos, resources, insights, etc. Any feedback or commentary is greatly appreciated. I think with a lot of discussion, we can make this a really robust and useful resource for future generation of med students.

Happy Studying!


  1. I hope you crush Step 1. By any chance, are you making your Anki cards public?

  2. @Anon1 yes his cards are public. He linked to them in the first paragraph of this post and talks about it here under the header "My Pathology Deck and More": http://drwillbe.blogspot.com/2012/02/studying-pathology.html

    @DrWillbe thanks for doing this! Just a quick question - do you think doing UWorld questions early like you did and then adding them to Anki is feasible for someone at a traditional 2+2 med school? Would the qbank be "wasted" on questions about material that hasn't been covered yet in 2nd year? What are your general thoughts on not wasting Uworld and other qbanks until dedicated study time? Thanks again!

    1. Hey Anon,

      Thanks for answering for me :) Yes, everything is here. It sounds like you're an avid reader of the blog.

      Regarding UWorld... I don't think you'd be wasting them if you did the questions that pertain to what you're studying at the moment. The key is making cards from the questions' explanations. The reason people usually advise against UWorld is because they think you'll forget the material by the time Step comes around. Without an SRS, I'd say that's true. But if you have a system to keep the UWorld nuggets in your head, you're all good.

      I would say though that you create enough of a gap between your first pass and second pass of UWorld so that you can't just answer questions from straight recall. I saw UWorld like 6-7 months ago, and as I do the questions now, I don't remember them from straight recall, so I think the twice-over strategy can work. You just need to give yourself enough of a gap.

      I've benefitted I think from being able to chew on and internalize the UWorld info over time. Doing 2K questions in 4-6 weeks isn't optimal for retention, but people still do very well like that.

      You might want to use a "lesser" qbank like USMLERx or Kaplan if you don't want to blow the good stuff early.

  3. > Events from one or more calendars could not be shown here because you do not have the permission to view them.

    1. Hey Gwern! Wow, thanks for checking out my site. I love your essay on SRS. Were you not able to see my calendar? I checked to make sure it's public.

      Anyway, thanks for stopping by. SRS is paying off big time, and I'm trying to spread the word to my med school colleagues.

    2. Nope, can't see it. Here's my screenshot: http://i.imgur.com/aQi43.png

      Also, you sure you want to spread the word? Even if only 1 in 100 actually starts using it, that's more competition...

  4. Good luck Dr Willbe. Per your advice, I've been following the Anki-lifestyle as well and am very curious to see how it turns out! I'm glad to hear the NMBE was encouraging -SB

  5. Dr WillBe: Good luck with the studying. I use your card decks (thank you!) and add my own material as well. I was wondering why you think you are weak in biochemistry: Was it because you spent the least amount of time on the biochemistry deck (10hrs) and having added more cards would have helped? Do you think it was because the deck should include more clinical connection to connect the biochemistry to the patho/physiology? Do you think it was because biochemistry at Duke was taught in the beginning and the deck would be better if it had not been at the beginning of the Anki-learning curve?

    Anyways, I absolutely love SRS and your resources. since I am a year out and I hear from Goljan tapes that many students are weak in biochemistry and the Board testmakers know it, I want to buttress my biochemistry knowledge.


    1. Hey. I think biochem is a weak area because I've given the least time to it. My school pretty much glossed over biochemistry, and since it was the first thing we did in med school, I didn't know enough at the time to disregard my course stuff and focus on what's gunna be on boards. Anyway, so I've had to back track and try to make a deck and learn stuff, and with clinical year in the way, I didn't have the time.

      But regardless, all is well. I'm building a solid biochem deck now. I co-opted a lot of cards from someone who posted a FA biochem deck on quizlet. It's not very good, but it's better than nothing. I'm doing UWorld right now and getting > 80% on biochem, so I'm not too worried.

      If I were going to start from scratch, I'd make sure to get everything in the FA biochem section (which I've done) and read Lippincott's Biochemistry (which I'm doing right now).

      But biochem in itself is not particularly difficult. Just a lot of memorizing and some logical connections (the more you see these, the better). Like everything else in med school, you just need the right time and the right tools.

      Good luck