Note: This was initially published in 6 parts and was then consolidated into a downloadable ebook.
Why create a study plan for the USMLE?
This is probably the question foremost in the mind of anyone who ever thought of tackling the USMLE. I remember when I was starting out, how this pre-occupied me a lot. Although studying for the USMLE is a big endeavor, studying how to study for the USMLE is no mean feat either. Just like an architect or engineer needs to plan out how to build a building before actually building it, we need to plan out how to prepare for the USMLE before we even begin studying.
Now some people can just jump right into reviewing and 3 to 5 months later take the exam and come out with a 99. I’m not one of those and so are I believe majority of those taking the USMLE. Some will start by applying and scheduling an exam 5 months later, only to find out that they’re not ready. So they extend their period of eligibility and still they’re not ready. Some will take the exam and fail or score so low that it amounts to the same thing. Some will forfeit the application fees and reapply later. Of those who do, some wind up getting good scores because they’ve learned their lesson and did better preparation this time, while for others the results are going to be poor because they did not change anything they’ve done before. Proper planning is crucial for proper preparation
Steps to creating a USMLE study plan.
Often, in forums, I’ve heard people refer to taking the USMLE in military terms. Going to War against the USMLE, they call it. Military generals never go to war without a thorough battle plan, that is if they expect to win and neither should you. We’ll be tackling this topic head on.
The Steps to creating a study plan are:
- Determine your objective
- Know thy enemy
- Know the learning process
- Know the components of a good study plan
- Know the factors that can affect your study plan
- Importance of sleep, rest and recreation
- Putting it all together
Determine your objective for the USMLE.
Just like all battle plans, you start out with what is your main objective.
- Is it to pass the exam?
- Get an average score?
- Beat the mean?
- Ace it?
High scores isn’t everything in the match. But it can make up for other deficiencies in your resume, like less than stellar grades in medical school, older grad, lack of USCE, etc. Often you see people in forums posting their study plans and asking if it is enough, but enough for what. Determining your objective is the first step in assessing whether your study plan is adequate or not.
So how high a score should you aim for? Well, it is a universal truth that most people do not achieve what they aim for so it is a good maxim to aim high. In the Greatest Salesman in the World, Og Mandino stated that
“It is better to aim for the moon and hit an eagle then to aim for the eagle and hit a rock.”
If you aim for a 75 and fail to reach it, you are in trouble. If you really want a 99 aim for a high 99 so you have points to spare in case not everything went as planned.
One word about setting objectives is to never set it in stone. As you finish your study plan and even as you begin your studies, you may find that your objective may change. Either you’ve underestimated yourself and have found out that you could do better, or your situation’s change, (e.g. your wife gets pregnant or you got pregnant, lost your job, got promoted, etc.) Do not be afraid to reset your objective, just be aware how it will impact your over-all chance in the match.
We’ve often heard about how people downgrade their objectives when they are unable to follow through on their plans. But how often have you heard of people who failed to upgrade their objectives when presented with the opportunity.
In 1863, on the first day of the Battle of Gettysburg, when Gen. Robert E. Lee’s Confederate Army defeated the Union Soldiers defending the three ridges south of Gettysburg, Lt. Gen. Robert Ewell refused to take Cemetery Hill, which wasn’t part of the original Battle Plan, even though it was lightly defended at that time. On days 2 and 3 after Cemetery Hill was reinforced by Union troops, the Confederates made numerous charges to take Cemetery Hill to no avail. This led to the famous Pickett’s charge by 12,500 Confederate troops on the 3rd day of battle which was repulsed by union rifle and artillery fire at great loss to the Confederates. By refusing to upgrade his objective, Gen. Ewell missed an opportunity that could have changed the outcome of the war and the destiny of the United States.
Know thy enemy.
Now like all good Generals, we have decided on our main objective for the USMLE. The next step is to study the nature of the enemy, only then can we know how to defeat it.
Now someone might say, why don’t you just post a study plan and like good soldiers we will follow them. Well that would be easier for me, but I doubt it will work or be effective for a lot of you. You see, a plan presumes that there is an objective, takes into account where you are coming from, your skills and particular strengths and weaknesses and your particular condition. A one-size fits all plan presumes you have the same objective, the same skill sets, the same background and the same prevailing environment which is just not true.
Now normally when somebody asks you how to go to Times Square, you presume he is somewhere in NY. But in the internet, the person may be in San Francisco, Baltimore, London, Karachi or even Manila. And the answer would be different in each case.
So too must your study plan be different depending on your particular circumstances. Just as a doctor tailor makes his treatment plans depending on your circumstances (child, adult, geriatrics or healthy, immuno-compromised, debilitated) we must tailor make our study plans accordingly. But just as doctors have treatment guidelines to guide them in formulating a good treatment plan, so too does this book attempt to provide you with guidelines on how to study to help you formulate a good study plan.
The purpose of the USMLE Step 1 is to test your knowledge of Basic Science concepts relevant to the practice of Medicine and to that extent it has been faithful. All questions you will find are related to the basic sciences like pathology, microbiology, pharmacology, etc. However, to emphasize its relation to the practice of Medicine, a lot of the questions are in the form of clinical vignettes. In Step 1, most of the Clinical Vignettes are classical presentations rather than atypical presentations. For more information about Clinical Vignettes, refer to my post here and here
Another thing you’ll notice is that whereas in Step 2 and 3, the cases are usually common diseases, Step 1 cases includes a lot of diseases that are fairly uncommon. The reason is that USMLE Step 1 emphasizes basic sciences and sometimes, important basic science concepts are illustrated by uncommon diseases. For example, Angelman and Prader-Willi Syndromes are fairly uncommon but demonstrates the principle of Imprinting. Small cell CA of the lung demonstrates the concept of para-neoplastic syndrome but is actually less common than squamous cell CA or AdenoCA. So this should guide what you should emphasize on your review.
All USMLE Steps also require you to be able to recall all this information in a minute or so. What you cannot recall, you do not know as far as the USMLE is concerned. So knowing something is not enough, you must be able to recall it too. Increasingly, questions are 2 to 3 step in order to avoid aided recall from the answer choices themselves. (For more about different types of recall, refer to this post)
All this impacts what we have to study, how we study and what steps will be involve in our review in order to be able to do well in the exam. We will continue next time and talk about how we learn and master information and how to apply this in coming up with a study plan for the USMLE.
Know the learning process involved in preparing for the USMLE.
We now have our objective and we know what the USMLE wants us to know and in what form it will test us for that knowledge. The third part is to understand how we learn and accumulate knowledge.
I’ve found the following to be a useful framework for analyzing and understanding where I am in my review and assess my strength and weaknesses. Using this framework will help us not only in preparing our study plan, but also in assessing any problems we have during our review and remedying them. We can divide our review preparations into 3 parts.
1. Knowledge Acquisition (KA) – This is where you put information into your Knowledge Bank (KB) Most new graduates are extremely fine here (Except if you’re one of those who barely made it. Crammed for every test and promptly forgot everything afterwards. Most Old graduates and some IMG graduates usually have problems here. This can impact how long your review period should be and the amount of “hitting the books” you have to do.
2. Knowledge Recall or Review (KR) – This is how well you extract information from your KB. Most new graduates have some problem only here. FA and the QBanks makes a fantastic tool for improving Recall. So people with problems here (New grads mostly) usually give fantastic ratings to FA and Qbank. Other methods to improve recall include flashcards and group discussions. If you have a KA problem, you still have to do KR after you have remedied your KR problems.
3. Test Preparedness (TP) – If you are not familiar with CBT, MCQ or clinical slant to questions, this is where your problem is. Problems with sitting for 8 hour exam is also classified here. Difficulty in answering 2 to 3 step thinking questions and running out of time during the exam also falls here. This is where QBanks are the most effective.
How long, how detailed and how demanding your study plan will depend on where you are standing right now. If you have lot’s of KA’s to do, then you have your work cut out for you. Textbooks may even be in order and not just Study Notes and Outline Notes. If it’s mostly KR, then repetition, repetition and more repetition is the way to go, especially outline notes and Qbanks. If its TP then Kaplan and UW Qbank will be most helpful.
Know the components of a good study plan for the USMLE
We now discuss the different phases of a complete study plan.
The three phases are as follows
- Learning Phase: This is where you try to learn everything that you still do not know about medical concepts tested in the USMLE.
- Mastery Phase: at this point, you already know the concepts, you just need to put them into immediate recall so that you can recall them in the minute or so that USMLE requires.
- Psychological Preparation: It is important to prepare yourself both physically and mentally for the grueling 7 to 8 hour exam(16 hours for step 3). Failure to do so may mean low scores or worse failing the exam altogether.
Many people tends to skip the learning phase and go directly to the mastery phase by purchasing review books like FA or BRS then use them almost exclusively for their studies. Depending on your goals and your current situation, this could be either a minor problem or a catastrophic one. One cannot master what one does not know. You can’t review materials you do not know. You need to study them.
The longer you are out of medical school the more time you need to spend here. The lower your scores were during medical school, the more you need to concentrate in learning all the important concepts tested by the USMLE.
Even recent graduates who are very good students cannot remember everything they’ve studied and usually there are gaps in their knowledge due to a variety of reasons. (eg. Subject not covered by professor, etc.) Therefore, it still makes sense to realize that there will be concepts you do not know and the best place to prepare for them is during the learning phase. This is especially crucial because you should not schedule your exam before you finish your learning phase (a common mistake committed by many). You should only schedule the exam once you are in your mastery phase where the time frame for accomplishing most preparations is more predictable. We will deal with scheduling later.
The mastery phase is what most thinks of when they talk of reviewing and in truth for most people, this is where most of their preparations should be. The main objective of the mastery phase is to get as many information as possible into immediate recall so that one can do well in a timed exam like the USMLE. (Refer to my post on different types of recall here.) Given enough time, one can recall almost anything one has learned and that’s the reason USMLE is a timed exam. It wants to test how much material you’ve mastered rather than how much you’ve learned. Outline notes, Qbanks and Flashcards are the way to go during mastery phase.
The psychological preparation phase is commonly skipped and yet many times this can be crucial to doing well in the examination or even passing it. Even if you are physically able to finish 8 hours, being mentally alert by the 6th to 7th hour is not that easy. Horror stories abound of people panicking and going blank during the examination.
In boxing for example, Boxers do not do much training in the last week before the fight. They’ve finished their training by then and if they’ve not then there is a big chance they will lose. However, they still go to the gym not to train but to keep focus and to prepare themselves for the upcoming bout. Therefore, it is important to give yourself time before the exam to physically recuperate from a long and arduous preparation and mentally focus on the upcoming examination.
Know the factors that can affect your USMLE study plan.
We will now discuss the various aspects that make making a one size fits all study plan practically impossible. This will be just an overview and we will discuss them in more detail later.
An important factor that will affect how you prepare for the USMLE is your background.
- Are you a recent graduate or an old one?
- AMG? Or IMG?
- Good student acing all exams? Or barely made it through medical school?
- Top school, run of the mill or diploma mill?
- English as medium of instruction or other language?
- Native English speaker or poor in English? (Having to translate the questions in your head can just be enough to break the exam for you.)
Any of these factors will affect how you prepare, how long you prepare and what additional steps you have to take in order to be ready for the USMLE.
Another important factor is your strengths and weaknesses and particular skill sets which you possess.
- Fast reader vs. slow reader?
- Good comprehension skills vs. weak comprehension skills.
- Good memory and retention vs. poor memory and retention.
- High IQ vs. very High IQ. (It is presumed that since you finished medical school, you probably have a high IQ or at least above average. A minimum IQ of 125 is needed in order to reasonably finish Medical school in the time allotted for it.)
- Whether you study better by reading, listening to lectures or group discussion.
- Long attention span vs. short attention span.
- Good concentration vs. easily distracted.
- Strong self-discipline vs. poor self discipline.
- Favorite subject. (You tend to learn and retain better information on subjects you like and if they happen to be heavily tested subjects, ie. Patho, Micro and Pharma in Step 1 or IM in step 2 and 3, this could influence how well your review will go. If you hate them, it will be harder.)
Last, but not least, your present circumstances can affect not only your study schedule but how high a score you should be aiming for.
- Working full time, part time, jobless.
- Head of the Family and sole breadwinner
- Have small kids particularly toddlers and infants
- Amount of Social support you can draw on
- Parents take care of all financial needs (The social pressures from relatives can be particularly demanding in this situation.)
- Family expectations
- Visa issues
- Your age and your health
All of the above circumstances will affect your study plan. It will also affect your schedule including when you should schedule your examination. Let’s look at them in more detail.
We will discuss how your educational background affects your study plans. We will go to the different aspect of your background.
New grad vs. Old grad.
High scores are more important to an old grad. Also the need for longer study time and additional responsibilities like work and taking care of kids makes their study plans much more complex and demanding than for new grads.
AMG vs. IMG.
IMGs need higher scores and longer study schedules than AMGs. AMGs have an advantage in Behavioral Sciences. US medical schools prepare AMGs to do well in the USMLE. This includes special pathophysiology classes and clinical correlations. While most IMGs are left on their own to integrate the concepts. That’s the reason for the popularity of Goljan’s lectures. When he goes “mechanisms, mechanisms, mechanisms”, he means “pathophysiology, pathophysiology, pathophysiology.”
To read more about the alleged differences between the difficulty of the exam for AMGs and IMGs, refer to my post here.
Good Student vs. Barely Made it.
If you barely made it through med school, then there probably are large gaps in your knowledge of concepts tested by the USMLE. It is important for you to hit the books, especially on frequently tested concepts you have not mastered. Even if you were a good student, there could still be some gap in your knowledge and it pays to go through outline notes like FA or BRS to find weak points.
Top school, run of the mill, or diploma mill?
There are topnotch graduates from diploma mill schools and there are really bad students from top schools, but on average you expect students from top schools to do better, therefore your school can affect how much preparation you need to make.
English as medium of instruction.
Even if you are proficient in English, having learned medicine in a foreign language can affect you. Most medical terms are not taught or learned outside of school. English is the medium of instruction at our school. Although I am proficient in both Filipino and Chinese, I learned medical terms in Filipino only after long practice and still have difficulty with medical terminology in Chinese.
Native English Speaker or Poor in English
The USMLE is in English and having to translate medical terms and even regular words in your head can slow you down a lot. In a timed exam like the USMLE, it could prove fatal. So if you have language problems, work on it first before attempting the USMLE.
Your educational background can and will impact your performance in the USMLE. Make sure you take that into consideration in your preparation.
Your Strengths and Weaknesses
We will deal with how your particular strengths and weakness impacts your study plan. Different people possess different skill sets. Your particular skill set will determine how you should conduct your review.
Fast vs. Slow Reader
Fast readers have a tremendous advantage in reviewing. If you are a slow reader, read up on some tips to increase reading speed in my post here. Also fast readers have an advantage when tackling the kilometric questions that appear in Step 2 CK.
Good Comprehension Skills vs. Poor Comprehension Skills
If you have poor comprehension skills, compensate by rereading the topics if needed. You need to understand it to learn it. What matters if you finish fast but did not learn anything. Again, main reason why you should not schedule examination until you finish your learning phase, since how fast you learn is variable.
Good memory vs. poor memory
Memorization is just repetition. If you have poor memory, do more repetition. Mnemonics is unreliable most of the time due to time constraints of the exam. Frequently tested material must be in immediate recall. Use mnemonics for more peripheral, less tested information.
High IQ vs. Very High IQ
If you finish med school than you can pass the USMLE. You just need proper preparation. The USMLE is tough but definitely doable. Having a Very High IQ just makes it easier.
Study Mode: Reading, Lectures, Group Discussions, etc.
Some people learn better reading, others hearing lectures and others by group discussion. As I said before people learn best by association. A lot of times you remember facts not because you read them, but because the lecturer said something humorous or you remember a particular incident during group discussions. Different people learn better in different environment. Understand what environment suits you best and include that in your study plan.
Good Concentration vs. easily distracted.
Some people can study with the TV on while wearing an ipod and with children wailing in the background. Others need absolute quiet to study. You should determine under what environment you can study well. Phone calls, social events and other distractions will affect how long your preparation will eventually be.
Long attention span vs. short attention span.
Some can study for hours, while others get bored after some time. Schedule your review to take this into consideration. Short attention span can be offset by variety, either in topics reviewed or in study mode. For example, studying pathology and anatomy or physiology in parallel or alternately can offset boredom. Alternating between reading, taking short quizzes, group discussion and listening to lectures can also offset boredom.
Strong self-discipline vs. poor self-discipline.
Some people can make a study plan and stick to it. Others, well, others make a study plan and try to stick to it. (wink..wink..) If you lack self-discipline, it’s best to recruit others to help you. Enrolling in a class (and showing up) can help. Joining a study group can also help. Do not schedule your exam in the hope it will force you to stick to the plan. You’ll wind up losing $$ or failing the exam.
Pathology, Anatomy and Physiology are my favorite basic science subjects in Med School. Which just means that I tend to study and retain what I study on these subjects. You probably mastered more medical concepts in your favorite subjects than others. When reviewing for the USMLE you need to concentrate on the big subjects rather than what is your favorite subject. The big three is pathology, pharmacology and microbiology. If these are not your favorite subject then you know you have your work cut out with you. If they happen to be, then you probably can make do with less study time.
Your Present Circumstances
Each one of us have a life outside of studying for the USMLE. We will analyze how your present circumstances affect your study plan.
Working full time, part time, jobless.
Some people have to work full-time. Which just means that they have to consider that their review period will be longer and that their schedule will be constantly interrupted. It is important for them to make sure that they set aside time for study and during those set time to isolate themselves from worries at work. The same could be said of those who work part time although their problem is not as bad as full-timer.
Head of the Family and sole breadwinner
Being head of the family and sole breadwinner is more challenging than just being employed. The pressure is physical, emotional and psychological. Having adequate social support is crucial if you want to pass or do well in the USMLE
Pregnancy brings with it a lot of problems not the least of which is going into labor at an inconvenient time.(eg. Like in the middle of the exam) Preparation for the exam and the exam itself are extremely high stress situation, so proceed with caution.
Have small kids particularly toddlers and infants
Children are fascinating, cute and lovable except when they won’t eat, become cranky and irritable. Then they’re nearly impossible. Hats off to all USMLE takers who have toddlers and infants and still able to study well. For others, well, asking for help from other adult family members may be needed. So it is important to anticipate and prepare for this before start of preparation.
Amount of Social support you can draw on
Support from family, relatives and friends can make a difference in your psychological preparedness for both the preparation phase and actual examination. There is a difference if people are rooting for your success or your failure.
Parents take care of all financial needs
Most new grads belong in this category. It is both a blessing and for some also a burden. The pressure to succeed at your first try because somebody else is paying for it can be overwhelming. Although for some there may also be a tendency to take it easy since they don’t have to worry about the financial burden.
High family expectations can be a spur to do well, or can hamper performance. Low family expectations can result in the same things as well. Again the result differs depends on each individual’s particular situation and their reaction to them.
You need to take the Step 2 CS exam in the United States and if you need a visa to enter the US, you will need to anticipate the time delay it takes to get one. So schedule your review with that in mind.
Your age and your health
Suffice to say, younger people have more stamina than those older, although you can also say that older people may be wiser. In addition, poor health can affect concentration and study time.
Now we talk about scheduling. There are different aspects of scheduling that we have to consider. Foremost is in what order do I take the USMLE. For AMGs the answer is moot and academic, since this is dictated more by the medical school than personal preference. For IMGs, who are free to chose their own sequence, it is more problematic. While it is true that for some IMGs it is more beneficial to take the USMLE Step 2 CK, I believe that for majority of exam takers, taking it in sequence provides tremendous benefits. I’ll discuss the reasons in more detail in a future post in my blog.
The next consideration is how long a preparation time should I allot for review. Again, this is so dependent on individual differences, it is hard to give an estimate. However, for the ideal graduate, meaning fresh grad, good student from good school, 2 to 3 months for Step 1 and 1 to 2 months for Step 2 CK is about average to pass and do well but not to ace the exam. (Again, there are geniuses who probably will be able to ace the exam, though) But outside of ideal, you will have to make adjustments.
Often, I see in forums people who will declare that they’ve signed up to take the examination in 5 or 6 months (or 2 or 3 or whatever), then ask plaintively, “what do I do now?” All I could do is shake my head since they are headed for disaster.
I have already discussed about the learning phase and mastery phase in your study plan. Mastery phase is most predictable. Usually 2 to 3 months to pass Step 1 on average and 3 to 4 months to ace it. Other factors like reading speed, IQ, available study time, etc. will affect it but the estimates are average. The learning phase is most unpredictable. That is why you should not schedule your examination until you are starting your mastery phase.
The last advice I can give is to schedule your exam to achieve a certain score rather than to finish by a certain date. By all means schedule your exam to finish by a certain date but if by that date you are not ready then postpone the exam. It takes as much time, effort and money to retake an exam as to cancel it and take it later. Except if you fail and retake it, it can do irreparable harm to your ability to match.
Importance of sleep, rest and recreation.
Having enough sleep, rest and recreation is very important in the review process. The worst time to burn out is just before the actual exam day. Also, studies have shown that neural connections are made during sleep and that unless we sleep, whatever we have learned during the day is not stored in long term memory. Infants sleep all day, because they have more information to process than adults. So not sleeping to study is not considered good quid pro quo.
Rest breaks are also important within the day as monotony will tend to dull your attention. Your eyes may be moving through the words but your brain is not recording it. 45 to 50 minutes study with 10 to 15 minute break is a good rule of thumb although again, personal differences may mean you have to adjust the actual rest break.
Now, there will be people whose total review period will go beyond 5 to 6 months due to circumstances not within their control and as such, they will need to have a break. Burn out is a big possibility and it is better to extend total preparation time by a month to rest in between.
We have finished our short guide on how to create a study plan for the USMLE. I hope that this will help people prepare better for the examination. From time to time, this guide will be updated and revised, so it may be a good idea to visit my blog to see if there is an updated edition.