Askdoc's USMLE Newsletter

What Makes the USMLE Step 1 Hard

Hi there,

Glad to see you are still with me. Haven't scared you off or bored you to death, yet, I hope. Lol.

I think you will agree with me:

The USMLE Step 1 is a hard exam. Anyone who says otherwise is a either a liar or trying to keep a brave face.


If you take the time to know what makes the USMLE Step 1 hard, then you can formulate strategies to counteract them and make the exam easier for you.

Saadi Medieval Persian Poet

Have Patience. All things are difficult first before they become easy.

The Journey Begins

It is a waste of time, money and effort to fail the USMLE and redo your prep because you prepped the wrong way. Not to mention the emotional turmoil that ensues. Plus it can wreak havoc to your chance of getting into a residency position especially if you are an IMG.

That was what was going through my mind when I started thinking about taking the USMLE Steps way back in 2004. At that time, I was 15 years out of medical school and have not opened a basic science medical text for over a decade. Like you I pored over books, forums and blogs to find out how to tackle this beast. Like most of you I was dismayed at how much lack of information and disinformation there were out there in the web.

I read thru hundreds of exam experience to find out what to do. I bought books, lots of them. Then I used what I knew to be good study methods and habits and created a study plan. After 7.5 months, I was ready to try out for the exam. So did it work? You bet it did. I aced Step 1 with a score of 99/256. And using the same study methods with some modifications, I successfully aced Step 2 CK with a score of 99/258.

If you noticed, the first thing I did is research what the USMLE Step 1 is all about. I put particular emphasis on what made the USMLE hard and how to overcome these difficulties. I also studied exceptional study methods people used to overcome these difficulties as well as study materials they used that made a huge impact on their scores.

I pored over hundreds of published exam experience in forums. Like most of you, I avidly read through exam experience of people who aced this exam, trying to glean the secret to USMLE success. Wishing that I was one of them.

It's fine to celebrate success, but t is more important to heed the lessons of failure.

Bill Gates
Founder, Microsoft

Bill Gate said, "It's fine to celebrate success, but t is more important to heed the lessons of failure."

So unlike most people, I also studied exam experiences of people who failed the exam. To see what they did wrong. What tripped them up. What they had difficulty with. In fact, this is where I discovered most of what made Step 1 a difficult exam.

I initially went through exam experiences of AMGs, but later choose to discard them. I mean, the only way I can make their study plans work for me is to go back to medical school and enroll in an American Medical College. LoL.

First Clue

So, what did I find out?

One of the most important reason why the USMLE Step 1 is hard is because of the wide coverage of the exam. As I went through the USMLE website, I noticed that Step 1 covers about everything just about everything I studied in the first two years of medical school. And based on some of the exam experience I read, also journals published in the last five years on basic sciences.

When I first realized this fact, two things came immediately to mind. First the amount of materials I needed to study is huge. Second, the amount of materials, I need to remember and be able to recall fast is also pretty large.

I also know that you need to learn or understand something first, before you can start memorizing and being able to recall them in detail. They are two separate process.

To illustrate, have you ever attended a lecture where the lecturer is teaching something new. You were all excited because you learned something new and when you enthusiastically tried to explain it to your friend, you find that you have a hard time actually recalling every detail so your friend can understand it. It's because learning just requires you to understand the concept, while to be able to explain, you need to have memorized a lot of details. They are two separate process.

Anyway, back to the two problems.

The first is not a problem for third year medical students as they probably remember most of what they have studied. It's a small problem for fresh-grads since basic medical science is two to three years in the past. But they are huge problems for old IMGs like me. The amount of study time I needed is huge.

Not only do I have to cover topics that are not covered in my country's medical school, I need to cover topics I have forgotten and topics I never learned because they are new. Worse, I needed to identify and unlearn obsolete knowledge that are no longer true.

The last is not as easy as you think. I was still being tripped up by obsolete knowledge when I was doing online qbanks. They usually form the basis of common distractors in the questions.

The second problem applies to everybody. All of us have limited memory capacity. Some bigger, some smaller. But for the purpose of the USMLE, no one has enough memory capacity to memorize everything.

I actually have a really good memory. In fact I have a semi-photographic memory, which means I can memorize things fast and store large amounts of information in my head. But the sheer amount of things I need to remember still looks overwhelming.

I mean, back in medical school, even for shelf exams, you can study anatomy, take the exam, then begin forgetting it as you study for the physiology shelf exam. For the USMLE, you need to retain not just one, but all 7 subjects you have studied in your head all at once. You can't start forgetting anything, unlike the shelf exam. What took two years to study. That requires a different kind of memory all together.

One Solution

So how does knowing this helped me ace the USMLE Step 1?

They say "Necessity is the mother of invention." Since finding out how broad the coverage of Step 1, I made a decision not to study everything. I will just study as much as my brains can handle. So the next question I need to answer is what should I study?

Which brings us to the matter about high yield topics. Wait a minute, some of you will say. Just study the high yield stuff and it will be all good. Everybody knows that.

In reality that would be a big mistake. If you actually go through the exam experience of those who failed, most of them just studied the high yield stuff. (See "High Yield Concepts and the USMLE" and "What are High Yield Topics?")

The right way is to study both high and low yield stuff. High yield topics have a bigger chance coming out in the exam but not 100%. Low yield concepts have lower chances of coming out in the exam but not zero. So the right strategy is to study all the high yield stuff very well and as much low yield stuff as your brain could carry.

Knowing the high yield stuff really well will insure you will pass the exam, but the more low yield stuff you know the higher your score will be. So make sure you study both.

If you go through AMGs exam experiences, they mostly just studied the high yield stuff. However, you need to realize that they have studied both high and low yield stuff when their school prepped them. And since they are still third year medical students, a lot of low yield basic science stuff is still in their heads.

IMGs and especially old IMGs like me have to study both high and low yield stuff in their main prep and do a high yield review in the last two to three weeks before sitting for the exam.

Aside from doing research, I actually conducted an experiment of just studying the high yield to see if it works.

The conclusion?

It did not. If I had just followed people's advice without checking them out and testing them, I would probably have gotten a low score and maybe even failed Step 1.

It's not only important to realize that the USMLE is hard. It is also important to know the reasons why it is hard. So you can formulate solutions on how to make the exam easier for you. And the best way to do that is to do your research and test your solutions if they work.

Mike Nicol Uy, MD

Other Solutions

There are actually more study strategies I came up with and tested to deal with this particular problem and we will talk about more of them in future issues. Using study techniques that improved memorization effectiveness is one. Implementing methods to increase recall speed is another. Plus many, many more.

Anyway, this is just one reason, there are a lot more. I listed 7 of the more important reasons why the USMLE Step 1 is hard in my blog. (see "Why You Need to Master the USMLE Step 1")

If you want detailed discussion of everything I found out in my research of what makes the USMLE Step 1 hard and what steps I took to overcome them, you can refer to my book "How to Master the USMLE Step 1" available at Amazon.

There are 7 chapters that deal with just why the USMLE Step 1 is hard and 79 chapters that talk about strategies to solve each one. It's that detailed.

That is all for now. See you around next issue.


P.S. For the next issue, we will talk more about the three phases of USMLE prep and how to use that knowledge to design a better study plan.

Better Prep.

Easier Exam.

Higher Scores.

How to Master the USMLE Step 1 Seminar

Better Prep.

Easier Exam.

Higher Scores.

How to Master the USMLE Step 1 Book

Score HIgher. Read the Book.

An in-depth written guide on how to prep better and score higher for the USMLE Step 1. Read the book. Better Prep. Easier Exam. Higher Scores,

Score Higher. Listen to the Lecture

A 48-module lecture seminar on how to prep better and score higher for the USMLE Step 1. Listen to the Lecture. Better Prep. Easier Exam. Higher Scores.