To reach my current position as a general cardiologist, I have taken nine board exams. I have also been teaching medical students for over ten years with several colleagues who write questions for the USMLE Step 1 exam. Through this experience, I have observed a number of themes about what works and does not work for board preparation. I share these with you now in the hopes they may help you better prepare for Step 1.

1. Step 1 is a test of mechanisms. You will rarely be asked to choose the best diagnostic test or decide if surgery is indicated on Step 1. Questions usually describe a clinical scenario and ask about what’s happening at the organ, cellular, or molecular level. The exam tests your understanding of how diseases and drugs work. Higher-level clinical knowledge is not emphasized on Step 1. If you do see questions asking about clinical management of patients, they can usually be answered from knowledge of the underlying mechanism of disease.

2. You will only see classic disease presentations on Step 1. I once saw a man with a toothache whose symptoms were caused by myocardial ischemia. You will never see a case like this on Step 1. Every myocardial infarction will present will squeezing substernal chest pain. The boards only use classic presentations of disease on the Step 1 exam. Students at this level are not expected to recognize bizarre, unusual signs and symptoms. When learning about a disease, focus on the classic, typical presentation.

3. There is no recipe for success in board preparation. Every year, tens of thousands of students prepare for the Step 1 exam. If studying from certain resources in a certain way guaranteed a 270, it would have been figured out long ago and everyone would be doing it. There simply is no guaranteed path to a top score. If one student gets a 260 and ten students follow the same study plan exactly, not all ten will get a similar score, at most just one or two.

Because there is no recipe for success, you should never feel compelled to use any particular resource. Use only what works for you. It’s fine to explore resources based on suggestions of other students but don’t feel compelled to use them. Since nothing guarantees success, skipping a resource doesn’t guarantee failure. Some students feel they must use particular resources because “everyone is using it.” Don’t do this. No resource holds secrets to answering questions. Choose what works for you.

4. While preparing for Step 1, avoid talking with your classmates about your progress. Many students want to know where they stand. Are others preparing the same way as me? How am I progressing compared with my class? But asking classmates about board prep will only stress you out. Few of us are completely honest about our struggles and weaknesses. If you ask a friend, “How’s your studying going?” they will likely respond, “Oh, pretty good. I’m working my way through a few topics like…” They are far less likely to say, “Ugh. I just bombed a block of UWorld and tanked my last NBME. I can’t understand this physiology stuff at all…” It is human nature to share the good and conceal the bad about ourselves.

I have seen this time and again over the years: the best students tuck themselves away and study hidden from their peers. Maybe they study with a close friend or two, but that’s it. They rarely talk about their study plan, or ask others about theirs. The focus on their work and don’t get distracted by comparisons with others. These students always seem to end up with the highest scores.

5. Earning a top score on board exams requires guessing. Let’s suppose you need to answer 75% of questions correctly for a 250 on Step 1. One way to do this is by knowing the answer cold to 75% of the questions such that once you read the question you immediately know the answer. This is very unlikely. The material is too vast, the questions too complex. A second way to get 75% correct is to know the answer cold to 50% of questions, a more reasonable goal. For the remaining 50% of questions, narrow the answer choices down to two and guess. Statistically, you will get 50% of these correct leading to the 75% score you need.

75% Correct (answered easily) + 25% Incorrect (no idea of answer) = 75% correct

50% Correct (answered easily) + 50% Guess (two answers = half correct) = 75% correct

If you can’t narrow the choices to two answers, narrow to three. Do anything you can to increase your chances when you guess. On every board exam no matter how much you prepare there will be guessing. Don’t panic. Guessing is not an indication of poor preparation; it’s normal. You must get comfortable narrowing down the answers and guessing if you want a top score on Step 1.

In general, be prepared for many questions on exam day where the answer is not immediately obvious. Some students go through dozens of resources hoping to “see everything” before their exam. This cannot be done. No matter how intense your studying, unfamiliar material will be on your exam. You will have to use reason and logic to find the answer, not just recall. Get used to this idea. This will happen on Step 1 and every other board exam in your career.

Jason Ryan is a cardiologist and founder and CEO, Boards and Beyond.

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