Ask any medical student how to do well on the USMLE® Step 1 or COMLEX® Step 1, and you will get ten different answers. To create a more empirical approach, I interviewed hundreds of neurosurgery and general surgery residency candidates who typically achieve very high scores to get an interview over the last twenty-five years. I have summarized the most common responses and created ten tips that I believe students may find helpful.
It has been my practice to ask one key question that I find reveals not only a students approach to studying, but also the potential residents work ethic and approach to education; which in my mind is very important to being a successful doctor; and in particular; to survive a long and arduous 5-8 year general or neurosurgery residency. So the one question I ask in every interview is:
Congratulations on your high basic science scores, so what was your secret to success?
The following top 10 tips are divided into four categories: LONG-TERM STUDY, SHORT-TERM STUDY, QUESTIONS, AND GOALS. I am hopeful this consolidated list will help you achieve a higher score on the USMLE® Step 1 or COMLEX® Step 1 that will improve your chances of training in a field and location of your choice.
Commit To A Long-Term Study Plan
Students who are thinking about a competitive specialty almost always focus on doing well in both classes and the USMLE® Step 1 or COMLEX® Step 1 starting in their first medical school year. These students know their long-term goal and realize it begins with a combination of doing well in classes but also learning to do well on USMLE® and COMLEX® board exams.
The simple reality is that if you do well in classes and receive mediocre USMLE® Step 1 or COMLEX® Step 1, you will probably have a difficult time matching. However, if you do extremely well on the USMLE® Step 1 or COMLEX® Step 1 and average in classes, you are more likely to succeed. Many medical schools are pass-fail, or if they do have grades, program directors have little understanding of how stringent the grading system is in your school. However, the USMLE® and COMLEX® are the great equalizers, so, like it or not, this is usually their first consideration.
Students that score the highest on USMLE® Step 1 or COMLEX® Step 1 start doing daily practice questions for these tests as soon as medical school begins. Try to find an online system that offers thousands of questions and allows you year-round access. Considering you are paying $20,000-$50,000 for each year of medical school, paying $1000 a year to Kaplan, BoardVitals, UWorld, Ambrose, or StatPearls for access to thousands of practice questions is a small price to pay for residency program matching success.
TIP 1: Start studying for the USMLE® Step 1 or COMLEX® Step 1 early, do thousands of questions, and budget time daily.
“Life freed from all responsibility or from ordinary hardships retains little to urge man on to accomplishment.”
Frederick E. Jackson, M.D.
While a small percentage of the students who do well on the USMLE® Step 1 or COMLEX® Step 1 are gifted with prodigious memories, the vast majority simply learn by identifying weaknesses and knowledge gaps and then reviewing the concepts until they become fixed in their long-term memory.
Most of the online systems allow students to flag challenging questions. Students who outperform their peers repeatedly intimated that not only did they study new questions daily, they regularly repeated questions they missed.
TIP 2: Repeat questions you miss until you are confident you understand the concept.
“It’s what you learn after you know it all that counts.”
Harry S. Truman
Plan For Time
Over the years, I have been amazed and perplexed at students who find excuses for not budgeting adequate study time in the months prior to the USMLE® Step 1 or COMLEX® Step 1 exams. Often they think it is only the brilliant, gifted students that succeed in achieving the highest scores. This is nonsense.
Invariably, the students that consistently have the highest scores indicated that during the first two years of medical school spent time every day preparing for the USMLE® Step 1 or COMLEX® Step 1, but in addition, they really ramped up their study time starting in the December-January break, and then really ramp up review in the six months prior to the exam doubling their daily time, then culminating with arranging their clinical rotation schedules to take an entire month off prior to the test. During this month, most mention they did multiple timed practice tests while constantly reviewing any question they missed and budgeting a portion of their day for reviewing key concepts.
TIP 3: Increase study time in the final six months, and allow one month of focused review time prior to the exam.
“I know of no more encouraging fact than the unquestionable ability of a man to elevate his life by a conscious endeavor.”
Henry David Thoreau
Do Practice Exams
The USMLE, NBME®️, COMLEX, or NBOME®️ all provide practice board exams that simulate the actual test. Students that scored well on boards consistently did multiple timed practice exams in the months prior to the test to build their timing, knowledge of the test and identify weaknesses.
Many indicated they went over any question they missed and reviewed concepts they felt were concerning. Some noted that doing timed, full-length practice tests on the weekends improved their endurance for the actual test day.
TIP 4: Do timed USMLE® Step 1 and COMLEX® Step 1 exams from the USMLE, NBME, COMLEX, or NBOME.
“The toughest thing about success is that you’ve got to keep on being a success.”
Concentrate on High-Yield Questions
The vast majority of USMLE® Step 1 and COMLEX® Step 1 questions are basic science or application of basic science to clinical situations. A few questions may be more clinical, but the vast majority will involve anatomy, neuroanatomy, histology, embryology, physiology, biochemistry, pathology, microbiology, and pharmacology. Students that scored well focused most of their time on basic science principles and their application rather than signs, symptoms, and treatment issues.
TIP 5: Spend the majority of your study time doing practice questions that cover the application of clinical medicine to basic science.
“It is not enough to be busy … the question is: what are we busy about?”
Henry David Thoreau
Quickly Analyze the Question
The questions on the USMLE® Step 1 and COMLEX® Step 1 tend to be very long case presentations that are often filled with fluff and superfluous information not needed to answer the question. Most students find it difficult to finish the exam in the time allotted and, as a result, miss questions simply because they run out of time. While most students practice doing thousands of questions, few focus a portion of their time on learning to quickly find the question being asked and then get to the answer quickly.
The students that do well learn to start at the end of the question stem and determine what question is being asked. Once they know what information the question is addressing, sometimes they can immediately answer the question without wasting precious further time. This extra time adds up, and in total, they end up having more time to complete the exam and increase their odds of finding more correct answers.
TIP 6: Go to the final sentence in the question, and see if you can answer it without wasting time reading the entire question stem.
“Nothing is more terrible than activity without insight.”
Eliminate the Choices
The questions on the USMLE® Step 1 and COMLEX® Step 1 often include multiple answer choices to diminish the student’s ability to narrow down the answer choices. Often you will face both a long question and a long list of answer choices. There is no easy solution, but the top-scoring students quickly review the final sentence in the question, then eliminate as many choices as possible, and only then quickly review the entire question to narrow the field further.
TIP 7: Review the final sentence of the question, eliminate as many answer choices as possible, then quickly skim the entire question to provide focused information needed to make your final decision.
“We rarely gain a higher or larger view except when it is forced upon us through struggles which we would avoid if we could.”
Epidemiology, Genetics, Expression Data, and Public Health Biostatistics and Experimental Design Questions
The USMLE® Step 1 and COMLEX® Step 1 includes multiple epidemiology, genetic, and public health-based biostatistical questions covering hypothesis, sampling, experimental design, data collection, descriptive tools, inferential statistics, statistical error, p-value, misspecification and robustness checks, hazard ratios, mean, median, McNemar, and Mann-Whitney U tests, experimental study design and interpretation, accuracy, sensitivity, specificity, predictive values, and Kaplan-Meyer curves. For most students, this is very difficult as you are expected to interpret complex research methodologies and statistical applications and apply them to clinical situations.
Students that do well on these questions emphasize they spent a lot of time reviewing the concepts and then doing multiple practice questions, becoming comfortable with calculations, terminology, and application. Make sure your mechanism of action and pathways. While most of the preparatory systems offer a few questions, this is one subject area that www.statpearls.com is a tremendous resource. The database in Statistics and Healthcare Economics includes approximately 150 questions and over 35 short review articles. Students that complete these questions and review the articles are likely to perform well on this portion of the exam.
TIP 8: Do a lot of epidemiological, genetics, expression data, study design, and public health biostatistical questions.
“There are three categories of falsehood: lies, damn lies, and statistics.”
Establish A Goal
Student’s that do well on the USMLE® Step 1 or COMLEX® Step 2 set a score they will achieve at all costs and then meet it. Knowing what you need to score from the start establishes a mindset that keeps you going from year to year, month to month, and then day to day as the exam date draws closer.
Set your goals high, and aim high. If you really want to guarantee a spot in a competitive residency, set a goal for a 260, and don’t slow down until you are consistently scoring above a 260 on practice exams. If you plan on a less competitive specialty, set a goal 10 points above the national average but remember, the more you learn, and the higher your score, the more likely you will be a better clinician as well.
Setting a deadline to reach the score you need 30 days before your actual test day is one strategy many of my successful students expressed. This gave them wiggle room and an opportunity to shore up any last many deficits. The fact is, it is a challenge to put in 12 hour days studying if you don’t first establish a light at the end of the tunnel.
Attaining a high score for most students requires being disciplined, sacrificing family life, social life while maintaining healthy habits like eating well and exercising. Basically, for six months, everything in your life should be geared toward achieving your goal.
TIP 9: Set a goal and meet it.
“Destiny is not a matter of chance, it is a matter of choice; it is not a thing to be waited for, it is a thing to be achieved.”
William Jennings Bryan
Students that believed they could achieve a high score on the USMLE® Step 1 or COMLEX® Step 1 usually did so, and the reason they achieved their high score was most often a combination of hard work and belief that it would pay off with success. One student that scored a 273 on the USMLE® Step 1, when I asked him how he did so well, quoted Thomas Jefferson “I believe in good luck, and the harder I work, and more I believe in myself, the luckier I get.”
In medicine, there is so much to learn and literally not enough hours in the day to learn it all. During examination preparation, you are constantly exposed to new facts while forgetting facts that you thought you learned. It is easy to become discouraged and develop negative thoughts.
Successful students develop a method to overcome their anxiety, face their fear, control their negative emotions, and move on. For myself, I memorized several famous quotes which I would recite, usually before an exam. Several of which I had shared with you as they had provided me with inspiration, many times when I realized even the greatest of men or women face adversity, and those that are truly successful, overcome.
TIP 10: To be successful on exam day, find a method to stay positive.
“The positive thinker sees the invisible, feels the intangible, and achieves the impossible.”
“The price of greatness is responsibility.”
“If you’re going through hell, keep going.”
The USMLE® Step 1 and COMLEX® Step 1 many students reflect are the single most difficult exams they have taken to date. The sage advice of planning a long and short-term approach of studying early, doing thousands of practice questions, and identifying and reviewing deficits is the primary key to success. Making sure you understand the questions and develop a method to get to the answer incrementally quickly increases your performance. But ultimately, when the test day finally arrives, you will arrive confident that you are fully prepared and ready to meet your goal.