HOW TO STUDY FOR THE USMLE

Gabriel Prada

**Manuscript Draft, 2019**

If you have built castles in the air, your work need not be lost; that is where they should be.
Now put the foundations under them.

—Henry David Thoreau, Walden

 CONTENTS

1. Preface
2. How to Study
• Theory
• Practice
3. How to Use a Qbank
• General rules
• Answering questions
• Reviewing questions
4. Study Plan
• Step 1
• Step 2 CK
5. Final Weeks
• Knowledge
• Conditioning
• Simulation
• Final two weeks plan
PROLOGUE

For every score-based competition or test, there are predetermined minimum and maximum
scores. Even though the maximum score is, in principle, attainable by anyone, mere observation
tells us that the higher the score, the fewer the people that can actually get it. It is my impression
that there is an egocentric cloud which prevents us from embracing our real place in matters of
score-based competitions. With adequate preparation, the following statements hold true for the
USMLE exams: most people can get an average score (Step 1/2 CK ~230/240); some people can
get a high score (Step 1/2 CK 240-260/250-270); most people cannot get a very high score (Step
1/2 CK >260/>270). I know, it sucks being against the odds. However, it is impossible to predict
whether you can get a high or very high score without actually undergoing adequate preparation
and taking the test. Hence, it does not matter what you think or believe or have been told; you
need to adequately prepare and take the test, accept and embrace your score, and move on. Now
that we have addressed the elephant in the room, let’s focus on what’s really important: adequate
preparation.

Adequate preparation is attainable by anybody. It can be yours only if you really want it. It
is not subject to randomness (ie, luck or the lack of it) as they are, indeed, optimal performance
and intelligence. For the USMLE, you can decide how you want to prepare for the test, but you
can’t decide or guess what actual test you will get. Knowing beforehand what subjects may show
up in your test, you can prepare accordingly, but everyone knows (or else shall soon find out) that
it is impossible to perfectly prepare such that you are absolutely certain you will get a perfect
score. It is impossible to know (ie, understand and memorize) all the material for Step 1 and Step
2 CK, no matter how much or how long you study. Thus, your otherwise unavoidably imperfect
preparation plus the uncertainty of the actual test you are to get are the sine qua non for your
performance being subject to randomness. What about intelligence? Intelligence (ie, IQ) is but a
product of randomness; the equation, your genes multiplied by the conditions in which you were
born and raised. Now, why am I spending an paragraph on randomness? Because it allows (or
rather forces) you to put the importance on the right place, on the right terms: adequate preparation.
Yes, again. And if you believe in luck or faith or destiny, I will tell you what Seneca said 2000
years ago: luck is what happens when preparation meets opportunity. No preparation, no luck.
This is so important I need two paragraphs and a fancy quote to make the point.
 Adequate preparation is about the quality of your study. Not quantity, that is, how much
or for how long you study. Not how many times (rounds) you do UWorld. Most importantly,
adequate preparation is not a human skill or an inherited trait. It is a method, a set of instructions
that, by definition, anyone is able to follow. You don’t need to be super smart, have great
memory, or be virtuous at multiple-choice tests. Yes... yes... of course: these cognitive qualities
(let’s call it above-average intelligence) translate, if anything, into higher scores. But what if I told
you that, in the realm of the USMLE, high scores come mostly from adequate preparation rather
than from above-average intelligence. Above-average intelligence, after all, is but a rather
infrequent human feature. What’s more, what if most of this so-called above-average intelligence
is not a superior ability at memorizing enzymes and cofactors, or finer skills at answering
multiple-choice questions, but instead is the ability to build and follow an adequate preparation
plan? Intelligence immediately becomes a transferable asset! Something you can actually get and
share. For the USMLE steps, among many other academic endeavors, I deem these statements
to be true. That is why the path preceding most high scores can be decoded into a general
pattern, clearly valid and reproducible not only for those that succeed in getting a very high
score, but also for the majority of us that, by definition, are expected to get an average score. For
it is, has always been, and will always be, about how you prepare, how you study, not how much
or how long you study. I did not invent this. It has been said and relentlessly confirmed by a
progressively larger, louder, diverse body of scientific evidence: the science of successful learning.

At this point, you might already know that this text is not about how to get your dreamed
score. Every time I see an ad proclaiming “How to get >260 on Step 1” my eyes roll back like
I’m the girl in The Exorcist, the three-eyed raven, or Tony Stark. Most of you will not get >260
on Step 1. I know it sounds discouraging, but it is a fact. Yet what everyone has in common is the
ability to reach their limits. This is the beauty of challenges such as the USMLE, for a substantial
amount of those high scores do not belong to the above-average-intelligence group, but instead to
the average-intelligence group that managed to maximize their capability through adequate
preparation. Correspondingly, I consider most of those that get low scores to belong not to a
below-average-intelligence group, but instead to a not-adequately-prepared group. It is precisely
by those that I am encouraged to write this text; those who must cope with greater difficulties,
with more hours and months of preparation, with more social, economic and personal
limitations, and, principally, those who have already failed or gotten a low score in Step 1 or Step
2 CK.

This text comes from and is directed to International Medical Graduates. After devoting
myself to the USMLE exams for more than a year during 2016 and 2017, and after speaking
extensively with hundreds of International Medical Graduates until the time of writing this words
(December 2019), herein I attempt to define, describe, and justify the backbone of an adequate
preparation for the USMLE Step 1 and Step 2 CK. Starting with an applied summary of the
most effective learning strategies according to scientific evidence (“How to study” section), I then
describe how you can use such learning strategies to take the most out of Question banks, by far
the most valuable educational resource for the USMLE exams (“How to Use a Qbank” section).
Next, I explain in detail the components of an adequate preparation for Step 1 and Step 2 CK,
for full- as well as part-time students (“Study Plan” section). Finally, I suggest a thorough and
strict plan for the final two weeks before your test day, aimed at fast-reviewing all the studied
material and enhancing physical and mental endurance (“Final Weeks” section).

Last but not least. Should you follow any of the advices you will find here, please let them
be the following:
- Please rest and sleep properly! I can’t stress this enough! The best way I can put it is this.
Adequate preparation without proper rest and sleep is, at best, a waste of time and
energy. Literally, it is as if I were deliberately writing this text on my laptop without
saving it, knowing that tonight it would autodelete itself once I turn off my laptop, yet
hoping that tomorrow I will recall every single word just because I carefully wrote it
today. In order for any preparation to be adequate at all, it has to be unconditionally and
consistently accompanied by proper rest and sleep. Among all the recommendations you
will find in this text, this one is the most strongly supported by scientific evidence.
- Sleep: consistently sleep at least 7 hours every night, particularly if you have
studied during that day or plan to study the day after. Bad sleep unequivocally
means that what you studied during that day or what you plan to study the day
after will not stick; that is, you will be unable to recall or understand the concept
on your test day.
- Rest: have at least one day (24 hours) free of study-related activities per week. No
exceptions. This will allow you to maintain the intensity of your study on the long
 term, especially by the end of your preparation, which is certainly the most
important part.
- Follow recommendations that you find frequently stated by people who got high scores
(Step 1/2 >240/250). I got 257/257, so read carefully!
- Do never follow literally and blindly one single piece of advice or study plan. Even if it
comes from Mr. 270/280.
 The eternal mystery of the world is its comprehensibility;
and the fact that it is comprehensible is a miracle.

—Albert Einstein

HOW TO STUDY

THEORY

You haven’t got a clue about who I am, right? Why, then, should you believe what I am about to
tell you? Simple: this is the only section on this text wherein every single word is based on
scientific evidence. You don’t believe me? Fair enough! One of the most essential skills of any
physician in the 21st century is to know very well how to find high-quality, evidence-based
information. Go ahead and check some recently-published papers on PubMed about learning
strategies or, even better, go through any of these exceptional books, the best on this topic in my
opinion:

- Brown, Peter C. (2014). Make it stick: the science of successful learning. Harvard
University Press.
- Carey, Benedict. (2014). How We Learn: The Surprising Truth About When, Where,
and Why It Happens. Random House.
- Horsley, Kevin. (2014). Unlimited Memory: How to Use Advanced Learning Strategies
to Learn Faster, Remember More and be More Productive. CK Publishing.

Now let’s get started. “Retrieval: From Old French retroeve-, stressed stem of retrover
‘find again” (First result on Google).

When you want to learn (i.e. understand and memorize) any given piece of information,
first you need to get to know the material; the first impression or exposure. This is the easy part.
You read a book or an article, listen to the teacher, watch a video. Then, my dear friend, there
comes the struggle. How can you take that information that has initially been placed on your
short-term memory slot and transfer it to your long-term memory slot? The answer is Retrieval!

Think of information as physical places in your brain. The first time you got to know
about this place was thanks to a path you were shown by a book, teacher or video.
Unfortunately, this path is made of footprints in the sand–or in the snow for those up north
because it starts to fade away the very moment you stop walking through it. But what if you build
other 5 different, additional paths that can take you to the same place? They would fade away
after you leave them anyways, but each at a different speed and extent, and, having several to
choose from, you would be able to decide, depending on where you are located (what type of
question you got on the USMLE), which one can take you more accurately and rapidly to the
respective place. Here is where Retrieval comes into play, for the creation of those paths are but
the result of the effort of your brain trying to retrieve that information. Every time you attempt to
recall some information, your brain first tries to use the already-established paths, and then, if
unable to find those old paths, it builds new paths by using information from other places (ie,
making associations).

Let me use a dynamic example following the “place in your brain” context. Any given
USMLE question will initially place you at O’Hare (one of Chicago’s airports), then it will throw
you a couple of hints like “cloud” and “loop”, and finally it will ask you to first “discover what
place it is” and then to state “how to get there”. With that, and only that, you will need to
remember that “loop” is how they call the downtown in Chicago, and that “cloud (gate)” is the
official, yet widely unknown, name of the “Bean” (the famous shiny, reflective, bean-shaped
public sculpture, located in Chicago’s downtown). Now you will need to remember “how to get
to that place” (from O’Hare). If you only know one way, namely, you take the Blue line Train,
get out at Washington station, and then walk all the way up to the east, you would get that
question wrong if the Blue line happens to be closed anywhere near downtown that day! At this
point you feel lost. Why don’t you know another route? Because you weren’t forced to find and
use it. You certainly read or saw several the first time you came to Chicago. But until this day,
you hadn’t had the need to use them, to retrieve them. They thus faded away and weren’t even
close to your long-term memory slot. Now, let’s not give up. Let’s try to retrieve. Say, you focus
and manage to recall that a Colombian friend of yours lives in Lakeview (north of Chicago), and
some time ago you had to go from O’Hare to his place, and afterwards, from his place to the
downtown. Can you see it now? You just retrieved pieces of information and built yourself a new
path, and, indeed, got that question right! Only after that day you will really have more than one
way to go from O’Hare to the Bean. Days bringing such obstacles and their consequent yet
valuable struggles will give you solid highways toward success!
 I know, I know… You thought you would create new paths by, every now and then,
checking–instead of using–some alternate routes just in case the Blue line closes, right? Or by
reading, highlighting and summarizing some books or watching different videos… You wish!
Your brain will always try to first find the easiest path (the law of least effort) and then to build a
new one. Re-checking, re-reading, re-watching, highlighting, summarizing, transcribing are
passive dynamics that give you the illusion of mastery, but what they really do is to make you
walk through the same path over and over again. You are, therefore, not getting much more of
what you got the first time you check, read, watched any given information. Retrieval doesn’t do
that. Retrieval, fueled by effort, makes new associations and builds new paths. Your success rate
in Qbanks and in the USMLE is but the reflection of how many paths you’ve got at your
disposal.

Now that we’ve got the “What”, we can proceed with the “How”.

Years of neuroscience research have found the basis of a successful Retrieval practice. It
can be explained under the development of the following four learning strategies: Generation,
Spaced Repetition, Interleaving, and Calibration. Before going through each of them, however,
allow me to explain you how is studying through Retrieval.

After getting familiar with the material (eg, reading, listening or watching it for the first
time) you need to focus on testing yourself. The very same way you used to draw nice flowcharts,
conceptual maps, data charts, or just highlight, you will now ask yourself about them. The main
concepts or key points you considered important enough to put them on those charts or to
highlight are the very same ones you will ask yourself about. Whether you use a question or draw
a flowchart leaving some gaps on it, is up to you. What you must always do is try to answer that
question or fill those gaps without looking at the material. Remember: Retrieval means effort,
and effort means learning. The more difficult the question, the fewer clues you give to yourself,
the more information you will need to recall (ie, more effort) in order to answer the question or
fill the gap, and, inevitably, the stickier the concept will get (long-term retention). That effort is
not only about making a thoughtful face and whispering as if you were praying. It is, in fact, your
brain gathering material (making associations) to build a new path to the answer. The time you
used to spend (or shall I say, to waste) re-reading, highlighting, summarizing (which is mostly
“selectively transcribing”), or drawing all sort of conceptual maps, you will now use it for testing
yourself. After trying to solve those tests or fill those gaps, you will check the material and correct
and/or complete what you just retrieved. By the end of the study session, not only you will have
actively reviewed the material, but also, and equally important, you will be able to identify what
are your weaknesses, what you haven’t understood, and indeed, what you need–and don’t need–
to work on in the future.

So far so good right! Now, I believe the best way to keep properly unfolding the subject is
by actually going through the four main strategies for a successful Retrieval practice. Remember
the golden rule: if it makes it harder, it will make it stickier. Effort means learning.

Generation

You already know this one. Answering open-ended questions requires much more effort than
answering multiple-choice questions. Drawing the complete flowchart requires more effort than
filling some gaps on it. Whatever you are recalling, try to do it as much extensive and complete as
possible. Moreover, try to answer much more of what you originally asked yourself about; ask
short questions, provide robust answers. If you are trying to remember why Beta blockers are
relatively contraindicated in diabetic patients, don’t just recall that it’s because they mask
hypoglycemic symptoms. Instead, try to recall the remaining side effects, their selectivity, and the
antidote in case of toxicity. Generate a wider answer. Use synonyms or slang in order to get the
point with other words, so you don’t merely repeat or paraphrase the same sentences from the
material.

Spaced Repetition

Retrieval practice is better when the concept you are trying to recall has faded away to some
extent, so you have to make an extra effort in order to get it back. Studies have shown that if you
give your brain some time to forget (space) what it has just learned, once recalled, it will stick
longer. Say, you and I read a paper about Sarcoidosis today. Let’s suppose that we had never
read anything about that disease. The day after we read the paper, you had to solve a first test
about it. Unlike you, I had to solve it five days later. One month after having read the paper for
the first time, you and I are given a new second test about Sarcoidosis. Guess who will get a 260
and who a 210 on that one! It’s not an assumption, it’s a fact! What happened is that, unlike you,
I had some time (five days) to forget about Sarcoidosis when I was given the first test, thus, in
order to answer it, I had to make a greater effort (compared to you) when trying to recall the
information I had read on the paper. The first test, as a Retrieval practice tool, yielded better
outcomes for me because of the extra effort that I had to make.

The take away message: after studying any specific material, give yourself enough time to
somewhat forget it, so when you try to retrieve it by testing yourself, you will be forced to struggle
a little bit more in order to get it back. Space your study sessions about a single topic, neither too
little time so you recall it too easily nor too long so you can’t remember anything at all.

Interleaving

The idea here is to detach yourself from the associations that helped you learn the material the
first time you studied it, thereby learning concepts independently, not needing to rely on single or
few associations anymore. Diuretics will make this clear.

Everybody learns diuretics in the same order the urine passes through the tubules.
Mannitol, Carbonic-anhydrase inhibitors, Loop diuretics, Thiazides, and finally Potassium-
sparing diuretics. Allow me to assume that you know them all very well. However, since you have
always studied them as a group of drugs, a sequence of channels, a one-way path through the
nephron, you necessarily rely on the associations you have made among them in order to recall
one or another. You could perfectly know Thiazides, yet if you happen to forget about Loops
diuretics just during your Step 1, you might not be able to recall all what you “know” about
Thiazides. You had always used the path from Mannitol through Potassium-sparing diuretics in
order to remember everything in between. Your dependence on that cluster of information, that
group of drugs, is dangerous. Here is where interleaving enhances–or rather corrects–your
learning.

As of now, you won’t try to remember about diuretics using that path. You won’t make a
flashcard asking for all the diuretics as a group. You won’t draw nice, colorful flowcharts of the
nephron and fill the gaps where every diuretic works. From now on, you will try to remember
diuretics using that path–but backwards. You will make a flashcard about Thiazides alone,
another about Carbonic-anhydrase inhibitors, another about diuretics that cause metabolic
alkalosis, and another about diuretics that are sulfonamides. Furthermore, you won’t study all
diuretics the same day. You study half of them today, and half of them three days or a week later.
You study one of those flashcards today, one different tomorrow, and one different next week,
and so forth. Likewise, you won’t study only biochemistry during this week. You study different
topics simultaneously, so you, from the very beginning, grow independent from the
groups/orders/sequences in which the material is given. Thanks to Interleaving, you will learn
every topic both on association with prior knowledge and independently as if your brain was
completely empty. Needless to say, you will never use Qbanks by answering blocks of a single
subject or subspecialty; always use mixed blocks, with questions about multiple, if not all, subjects
or subspecialties.

Calibration

Quality over quantity. Your study time must be wisely distributed, giving more attention (ie, time
and effort) to your weaknesses. USMLE exams are not about fully reading and getting familiar
with the material. That’s not enough. Before your test day, you will need to have reviewed every
topic so many times that you wouldn’t believe me. Here is where Calibration plays a role.

Once you have initially studied all the material, you then need to focus on identifying
what particular points or concepts require further study. Since we are talking about months of
preparation, those weak points will be in constant variation. It is therefore of utmost importance
that you make a habit of identifying your weaknesses as they arise as well as they cease to be. It
sounds kind of abstract, I know. Pathoma will make it clear.

Pathoma is the most recommended pathology book for Step 1, and as you would expect,
people spend a considerable amount of time and effort trying to master it. What they do is
exactly what you shouldn’t do. People study Pathoma once when reading the Kaplan books at
the beginning of their preparation. Again, after reviewing First Aid or while doing the Kaplan
Qbank/RX Qbank. And again before, during, and after UWorld. I’m not kidding, they really do
that. What is wrong with studying so many times an undeniably high-yield book? They are
breaking the law of quality over quantity. They are wasting their time–wisely. What they should
do, if their goal is to completely master Pathoma, is identify the specific points that they haven’t
yet mastered and focus only on them. Those points, however, won’t be the same after reading
Pathoma for the first time, or after studying First Aid for the first time, or after finishing UWorld.

How do you identify your weaknesses? You already know it: Retrieval practice. Every day
when reviewing some topics, and of course when I say review I mean testing yourself, you will be
able to see what topics you find more difficult to recall, or the ones you can’t remember at all.
Retrieval practice tells you how to study and Calibration what to study.

Intervals***
PRACTICE

In this section I describe how to apply the previously explained learning strategies to your daily
study for the USMLE. Please remember: theoretically, everyone should stick to the basic
concepts, but practically, everyone is different and, thus, everyone should find what best suits
them (and shouldn’t follow literally what I am about to explain).

The Journal

For most of us who have embraced the above-mentioned learning strategies, The Journal is, by
far, the most valuable study tool one can use. Please read carefully and try to use it even if it
doesn’t seem too useful at first sight. Sadly, the evidence indeed has shown that any study device
that fundamentally includes Retreival practice, Spaced Repetition, and Interleaving appears to
the human mind as particularly counterintuitive and suspiciously useless.

What the name “The Journal” implies are its three main principles: 1) it is made,
produced 100% by you, 2) it is produced and used on a daily fashion, and 3) every page (day) is
unique. The Journal is a dynamic tool that allows you to actively and efficiently focus your time
on concepts you find either high yield (ie, frequently asked by the USMLE) or difficult to master,
what we will call “Target Concepts”.

Here it goes. During a regular study day (Day #1), as you review a certain quantity of
information (eg, books, notes, Qbanks), you are simultaneously identifying Target Concepts and
formulating questions about them on Page #1 of your Journal. At the end of your Day #1, you
will have written down a list questions about Target Concepts. The next day (Day #2), regardless
of what you intend to study that day, you will take Page #1 of your Journal (from Day #1) and
will spend 30 to 90 minutes trying to answer it by hand (Retrieval practice). As you continue
studying (new information) throughout your Day #2, you will have written down new questions
about new Target Concepts on Page #2 of your Journal. The next day (Day #3), regardless of
what you intend to study that day, you will take Page #2 of your Journal (from Day #2) and will
spend 30 to 90 minutes trying to answer it. Then, as you continue studying (new information)
throughout your Day #3, you will have written down new questions about new Target Concepts
on Page #3 of your Journal. The next day (Day #4), regardless of… I’m kidding, I know you
already got the point. Those who didn’t, please seek help, it’s never too late–and also take a look
at Table 1.

Table 1. The Journal (One day of Spaced Repetition)

Formulate Answer
Day #1 Page #1 None

Day #2 Page #2 Page #1

Page #2
Day #3 Page #3
Wrong questions from Page #1
Page #3
Day #4 Page #4
Wrongs questions from #1 and #2
Page #4
Day #5 Page #5
Wrongs questions from #2 and #3

Nothing explains better than a good example, right? Let us say that today is Day #1 and I
am studying Sarcoidosis and Leukemias or I did an UWorld block where I got wrong some
questions about Sarcoidosis and Leukemias. Throughout Day #1, I wrote down some questions
about the Target Concepts on Page #1 of my Journal. These are 4 questions of Page #1 of my
Journal, which I wrote down (formulated) during Day #1:

1. What electrolytic disorder is seen in Sarcoidosis, and why?

2. What is the only Leukemia that is not diagnosed by Flow Cytometry, and why?
3. What is the only Leukemia where I won’t find neither “B” symptoms nor
lymphadenopathies? And what is the other name of it? (because it’s got two names)
4. What kind of pathology I find in a lung and lymph node biopsy in Sarcoidosis? Write
other three diseases that cause the same pathology findings.

Today is Day #2, and before I start studying or doing my UWorld block, I am going to
answer Page #1 of my Journal, because I am a good student who trusts Gabriel and his rhetoric
about learning strategies. However, if I want to be a very, very good student who not only trusts
but understands Gabriel’s text, I will not answer Page #1 of my Journal during Day #2, but
instead during Day #3. Why? Because I want to really space my Retrieval practice (Spaced
Repetition) by 2 days instead of only 1 day; from the moment I write down the questions on
Page #1 to the moment I answer them. Two days is the perfect time to forget enough (but not
too much) and consequently have a more productive Retrieval practice (Table 2). One day is
not bad, though. Three days is too much.

Table 2. The Journal (Two days of Spaced Repetition)

Formulate Answer
Day #1 Page #1 None

Day #2 Page #2 None

Day #3 Page #3 Page #1

Page #2
Day #4 Page #4
Wrongs questions from #1
Page #3
Day #5 Page #5
Wrongs questions from #1 and #2

Here are the answers, which I write down on a piece of paper and then compare them
with my Review Book (First Aid, Master the Boards, UWorld).

1. What: Hypercalcemia. Why: Main pathologic phenomena in Sarcoidosis is the formation

of noncaseating granulomas which, by definition, are formed by Macrophages. If you
remember, these cells produce the enzyme 1-alfa-hydroxylase which converts 25-hydroxy
Vitamin D into 1,25-Dihidroxy Vitamin D and, given their overactive state in
Sarcoidosis, they end up producing higher levels of 1,25-Dihidroxy Vitamin D and,
consequently, increasing the intestinal absorption of Calcium (main role of Vitamin D in
Calcium homeostasis).
2. What: Chronic Myelogenous Leukemia. Why: its diagnosis is focused on the
identification of the Philadelphia Chromosome (9:22 translocation). Thus, we use FISH
 or PCR, not Flow Cytometry which detects clusters of differentiation (CD) and not
chromosomal abnormalities.
3. What: Hairy Cell Leukemia. Another name: Leukemic Reticuloendotheliosis.
4. What: Noncaseating granulomas. Other three causes: Crohn’s disease, Hypersensitive
pneumonitis, and Berylliosis.

Last but not least, after answering Page #1 of my Journal, the questions I got wrong or
couldn’t answer will be marked because I will try to answer them again the next day. Thus, on a
Journal with 2 days of Spaced Repetition, during Day #4, before I start studying or doing my
UWorld block, I am going to answer the wrong questions of Page #1 along with all the questions
of Page #2 of my Journal. During Day 5#, before I start studying or doing my UWorld block, I
am going to answer the wrong questions of Page #1 and Page 2 along with all the questions of
Page #3 of my Journal. So on and so forth. Thus, regardless of what subject you are studying
today, you are always working on your weaknesses as well as important concepts (Calibration).

The Journal, as you can see, allows you to identify the important (high yield) and difficult-
to-master concepts and study them under the light of Retrieval practice, Spaced Repetition,
Generation, Interleaving, and Generation–altogether, like a beautiful family, you their favorite
child!

Flashcards

A flashcard is a self-made, small piece of high-yield information that you review over and over
again, from the day you write it until the day before your test day. It is an accessory tool that
should not take a big part of your study time. If you study four to six hours a day, reviewing your
flashcards should not take more than 20 min. Do not forget it: the best flashcard is the one you
make yourself.

What subjects should be placed on them? Concepts that are both high yield and most
difficult to master. How am I going to review them? By following the rules of a successful
Retrieval practice.

- Generation: On the front of the flashcard, write as less information as possible. On the
back of the flashcard, write nothing but the page(s) of the book where the answer is,
 thereby forcing yourself to memorize the whole page and not what you believe is more
relevant. Furthermore, as you study and review UWorld, you will be constantly adding
new information to your Review Book, sort of updating it, and you don’t want to spend
more time updating both your book and the back of your flashcard.
- Spaced Repetition and Calibration: You will classify your flashcards according to your
level of mastery. The classification is dynamic and varies throughout your preparation, as
it is expected if you are doing a good job.

I suggest 3 groups:

- Group 1: Review twice a week: Monday and Thursday

- Group 2: Review twice a week: Tuesday and Friday
- Group 3: Review once a week: Wednesday

Flashcards on Groups 1 and 2 contain Target Concepts that you are just getting
familiar with or are still difficult to remember (ie, those you haven not mastered at all).
Flashcards on Group 3 contain Target Concepts you have already mastered. All
Flashcards should start either on Group 1 or 2 and then move onto Group 3. If you feel
that you know a Flashcard so well that you do not need to review it again, it means it
needs to be no more. It is no longer difficult to master.

- Interleaving: Do not make a Flashcard with all of types of Leukemias, another with all
Interleukins, and another with Trinucleotide repeat disorders. Do make one Flashcard
with two or three Leukemias plus the odd-numbered Interleukins plus the only two
Trinucleotide repeat disorders that are not autosomal dominant. Do another Flashcard
with the remaining two or three Leukemias plus the even-numbered Interleukins as well
as the Trinucleotide repeat disorders that are autosomal dominant.
- Calibration: Make the proper number of Flashcards so you can review them at least once
a week. It is worthless making a Flashcard that you will review only every two or three
weeks, let alone people who make hundreds of flashcards and end up learning only 10%
of them despite spending most of their study time writing and reviewing them. It is not
about how many you should make and review. It is about how much time will you spend
reviewing them. Remember, Flashcards are an accessory tool.
ANKI
 “Should we be mindful of dreams?” John asked. “Can we interpret them?”

The master looked into his eyes and said: “We should be mindful of everything, for we can
interpret everything”

—Hermann Hesse, The Glass Bead Game

HOW TO USE A QBANK

It’s clear enough that Qbanks (UWorld, Kaplan Qbank, USMLE-RX Qbank, Becker Qbank)
are the best study tool for the US medical boards. Thus, most of your study time should be spend
on those resources. But, why is that? If you guessed it, I’m super proud of you! Yes, using Qbanks
is retrieval practice at its finest. However, I don’t want to spend time explaining why it is so.
Instead, I want to focus on how to enhance the use of such a wonderful resource.

**MCQ value (cite knowledge map evidence)

Alert!! This is the most controversial topic around the USMLE preparation. People will
tell you to do UWorld three times so you memorize the questions and all the material, others will
tell you to do two or three blocks a day to get the endurance for the actual test, others that you
should review only the wrong questions, others that you should do blocks by subjects and not
mixed, so on and so forth. So please, by rephrasing what I wrote on the first page of this
document: “Follow advices only from people who got high scores (Step 1/2 >240/250). The
higher the score, the more reliable” and “do never follow literally and blindly one advice! Even if
it comes from Mr. 270!” As far as I’m concerned, I strongly believe that if you do it properly,
once is enough. What is properly? Keep reading!

GENERAL RULES

Start with Unused Untimed Mixed blocks of 40 questions

• Unused: always new questions. You get it. You’ll need to redo the wrong ones and the
marked ones but only at the end of your preparation. This part is explained at the end of
this text in the “Final Weeks” section.
 • Untimed: 60 min are not enough to take the most out of each question. If you’re
concerned about training yourself to finish every block on time, I understand you and
assure you that you can get the proper training by doing about 600 questions (15 blocks)
with the timer on. Therefore, given the 2400 questions (60 blocks) that UW offers, I
suggest you that, in order to follow the study dynamics here explained, you go for the first
75% of UW (1800 questions, 45 blocks) untimed, and the last 25% (600 questions 15
blocks) timed. More of this will be explained in the “Study Plan” section.
• Mixed: two reasons: (1) it’s the way your actual test will be given and (2) it’s also what
“interleaving” in retrieval practice means

Only one block a day

If you follow what I’m about to tell you, you’ll see that it’ll take you at least 6 to 8 hours to
properly answer and review one block (40 questions). You’re allowed to do more than one block
a day only when you’re about to finish UWorld (you have done more than 70% of the questions),
since you’ll need to get the endurance for the actual test.

ANSWERING QUESTIONS

When answering Qbanks, most people focus on two things: (1) getting the right answer/highest
score per block and (2) finishing on time (less than 60 min per block). This is understandable,
since the academically nourishing part of the Qbanks is seen only in the review part and not in
the answering one. Nonetheless, I’m telling you now that the answering part is as much
academically rich as the reviewing part. How come? By enhancing the mental process that you
go through when answering a question you get to take the most out of each one.

Every time you start reading a question, you will do so by dividing the question in 3 parts:
Vignette/Stem, Question, Choices. As you follow the next instructions, you should use the
“note” tool that you’ll find in all the Qbanks. Here you can write notes on every question while
you are answering the block. Write your doubts, why you picked that choice instead of the other,
why you are not sure about your pick, etc. Afterwards, when reviewing the questions, these notes
will guide you through your weak points and will remind you what you thought when answering
each question.
 Step by step this is how it goes:

(1) “Imagination is more important than knowledge” used to say Mr. Einstein!
Most of the questions will start with the age, sex and race of the patient. So you’d
better start by giving to the patient a real face and body. Pick a real face and body for the
white elderly male patient, may be your father. For the childbearing age African
American woman you might pick your ex-girlfriend (I know you haven’t forgotten her).
Choose people that you can easily remember, thereby, after reading the first line age, sex
and race, you automatically imagine the picture of that real person and from that first
line onward you just remember the face and body of that person instead of repeating
yourself the actual age, sex and race of the patient.
(2) Control the question and not the other way around
As you continue reading the vignette, you start thinking about possible differential
diagnosis. Period after period, you will stop and quickly summarize what you have read,
and by doing so you’ll take the positive symptoms/signs or relevant information and start
thinking about possible diagnosis. Then, right before getting to the Question, you stop
and try to anticipate or guess the question. By doing so, you force yourself to mentally
organize the information you were given and to recall concepts that could be asked
according to your academic suspicion. You’ll see that when you have no idea of what is
the diagnosis or the pathway given in the vignette, you go to the question or the choices
just to orientate yourself through the case. This is the easy way! And if you read the first
part of this paper, you already know why easy is not good for you.
(3) Better earned than given
Then, you read the question and without looking at the choices you try to answer
it. This part is crucial. I can’t stress this enough. This is all about “generation” in retrieval
practice. After thinking about the possible answer, you look at the choices and try to find
the one you had in mind.
(4) Make every choice correct!
Next, you rule out each of the other choices by mentally explaining yourself why
each of them is incorrect and by explaining to yourself what you would have to change in
the vignette (patient characteristics, labs results) in order to make every choice correct.
(5) Pick and move on
 Finally, if you are not sure about the choice you have picked, mark the question.
Then, and only then, you pass to the next question. Please do not stay on the question
after having picked your choice! Pick and move on! Now, I think you understand why I
talked about untimed blocks, nonetheless, as you practice, you’ll gain speed and fluency,
to the point where you’ll follow these steps automatically and finish the block on time.

REVIEWING QUESTIONS

Here you’ll understand why I say you should do (i.e. answer and review) only one block per day.

Think of the explanation of each question as a lecture about certain topic or a real patient. First
of all, if the topic is unknown or not completely understood, you need to focus more on that
lecture/patient (i.e. spend more time reviewing the wrong questions). Then, if you know which
the specific topic is, you’d better study beforehand in order to take the most out of that
lecture/patient. And finally, by learning about the topic explained in that lecture/patient, you
force yourself to study and consequently to learn about others related topics (i.e. those given by
the multiple choices/wrong choices). You can perfectly understand a topic from the books, but
you know that if you see a real patient (or get a question) with the symptoms and signs about that
topic, you’ll understand and memorize it better.

How to identify high-yield questions

What does this mean in real practice? You’ll start your review with the wrong and
marked questions and you’ll spend enough time with each one. I must say, however, that you
have to review each of the correct questions from head to toe, even if you think that you perfectly
know the topic. You have no idea about what you don’t know/what you are missing until UW
shows it to you. Therefore, review each question as thoroughly as if it was your single
opportunity to do so, as though you knew it will show up in your actual test, because it will!

Step by step this is how it goes:

(1) Why did you get it wrong?

Read the vignette once again (trying to answer the question again) and try to see
whether or not it was possible for you to have picked the right choice. Perhaps you
misinterpreted or misread some word, or just missed something. Here you find out how
 much you know, and mostly, what you don’t know about the topic and why you got that
question wrong.

(2) Good students always study before the lecture!

Open your Review Book (First Aid or Master the Boards) and read the pages and
your notes about the topic of the question. Then, with the information found in your
book and your notes, you see whether or not you are able to answer the question
correctly. This allows you to do a rapid review about the topic thereby getting
ready/competent enough for the explanation of the question given by UW (which you
haven’t yet seen) in order to better understand it and associate it with your prior
knowledge.

(3) The lecture

Now, and only now, you go through the explanation of the question. Read
thoroughly and complete your notes or Review Book with the missing information that
you find in UW. Spoiling alert! Anything that you find in UW could (and probably will)
show up in your actual test, so you`d better learn/understand/memorize every single
word. Fortunately, I cannot say the same about the other Qbanks.
(4) Make every choice correct (once again)!
As I said before, studying the case by focusing on the correct answer is not
enough! If you really want to improve, you need to study a broader material spectrum
than just the one given by each question. After having understood why the correct choice
was the right one, you need to understand why the wrong ones are incorrect! I know it
sounds obvious; however, this is the part that most of the people don’t understand nor do.
It’s not only about reading the two-three lines explanation given by UW. It’s about
reading the whole topic of each choice from your Review Book and notes. It’s about
thinking what the single word/patient characteristic/symptom/sign/lab is result that you
would have to change in order to make every choice correct. This exercise helps you find
out what the most important single fact about each topic is and also to study many topics
within a single question.
Employ your time in improving yourself by other people’s writings so that you should come easily
by what others have labored hard for.

—Socrates

STUDY PLAN

All I want for you is that you get the highest score you can get, not the one you want or need. I
know everybody wants a 260/270, however, as you’ll see, it’s not about just studying as much as
you can. If this was the case, all of those who study more than one or even two years would get a
270, and you’ll see that this is not the case! As a matter of fact, although this is only a short
individual experience, all of the >250/260 on Step 1/2 that I’ve met during these 18 months I’ve
been going to Kaplan center (Chicago) have studied for no more than 9 and 5 months for the
Step 1 and 2, respectively.

How can you reach the highest score you can get? By setting and following the best study
plan you can think of with the date of your actual test right after the end your plan. Please do not
say “I will study indefinitely and whenever I get an NBME/Self-Assessment above the score I
want to get, I will set a date and consequently take the test”. This is a naïve, mediocre and
dangerous thinking. Why naïve and mediocre? Because the score you want might not be the
highest score you can get! What is it then? You don’t know yet! When will you know it? When
you completely finish your best study plan! Why dangerous? Because even if your NBME/Self-
Assessments say that you’re above the score you want, you could happen to get a low
performance during the actual test and score 10 to 20 points below your range! If you are well
prepared, this wouldn’t mean a low score since this would be your highest score ever possible.
But if you’re under-prepared, this would definitely do.

Please see the logic and importance on each of the following steps and realize why it
might be the best study plan you can think of.

STEP 1

Kaplan books (2-3 months)

Please be aware that this is the only opportunity to review thoroughly every single topic! Please
do not take it lightly saying to yourself that “this is just a quick read in order to familiarize myself
with the material and not to completely understand or memorize it”. Again, if you do it properly,
once is enough. The idea is that you never have to come back to these books once you finish
them. If you do so, it means that you didn’t read this part. I suggest you do this by dividing the
books in two groups and subsequently interleaving them. One group is for those that are basically
a list of things that you must memorize: Anatomy, Microbiology, Pharmacology and Pathology.
The other is for those that are full of processes and dynamic concepts: Biochemistry, Physiology,
Genetics and Immunology. By interleaving I mean that you study them simultaneously, taking
two books at a time, one from each group and then going through them at the same time. Say,
you start with the couple Anatomy and Physiology. You start reading the first chapter of
Anatomy and once you finish that chapter, you start the first chapter of Physiology and once you
finish that chapter, you continue with the second chapter of Anatomy, so on and so forth.

Now, the secret! During the days you’re studying a certain chapter of Anatomy, you are
taking around one hour of your day for reviewing the topics that you have already studied about
Physiology. Then, during the days you’re studying a certain chapter of Physiology, you are taking
around one hour of your day for reviewing the topics that you have already studied about
Anatomy, back and forth. At the end of each week, you can do a big review of what you have
studied that week and the past weeks. Once you finished some books, you’ll have to take some
time to review them in order not to forget what you have learned. Say, you take Saturdays for
reviewing those books, so from Monday through Friday you focus on new books only, and on
Saturday only on old (already reviewed) books. How will you do this review? By using retrieval
practice! I myself used the journal for this, however, I believe that Kaplan Qbank is an excellent
resource for this purpose. You can start doing ten questions a day about the books you have
already read. It won’t (and it shouldn’t) take you more than one hour to answer and review 10
questions.

First Aid + Qbanks other than UWorld (1-2 months)

Once you have finished Kaplan books, it’s time to get started with the heavy stuff! First Aid (FA)
is the single most important book for Step 1, since every word you find there will potentially show
up on your actual test. Before doing any Qbank you need to read/review FA at least once. But
again, passive reading as a review method is not what I want you to do. That’s why I suggest you
start doing questions from this point onward. Use a Qbank in order to review FA from head to
toe. I suggest USMLE-RX Qbank for this purpose. Why? Because it’s written by the same guys
who wrote FA, so both the questions and their explanations are based on the content of FA. This
means you’ll always be reading high yield stuff! That’s why I cannot say the same about Becker
Qbank and Kaplan Qbank.

How should you do this? Split your time in (passive) reading and (active) questions. Half
of your day you read FA and the other half you go for twenty questions and review them using
FA as a Review Book (of course).

For how long? Until you are ready for UW. Normally it takes around 2 months.

When will I be ready? After one or two months doing questions and FA, you have to find
out if you are ready to start UW by taking an Assessment, which is normally an NBME CBSSA
(National Boards of Medical Examiners, Comprehensive Basic Science Self-Assessment), which
will be your first one! Do it untimed please! At this point you haven’t practiced (and you need not
so) the time for your blocks. If you get >215 then I consider you are ready to start UW.

Why >215? People say that by doing UW properly, you should except to raise your score
up to ten points per month of study (but no more) during the three or four months that it takes to
do the 2400 questions of UW. Thus, if you get 215 on your first NBME (right before starting
UW), you can expect to safely reach a 240 at the end of UW.

What if you get <215? You need to study FA better. You don’t need to read other books or
articles. FA is enough! I suggest you do one or two more months of questions, whether you use
USMLE-RX Qbank or Becker Qbank or Kaplan Qbank it’s up to you. The idea is that you
spend more time trying to understand and memorize FA by doing questions and reviewing them
the way I told you. Then, you take another NBME and find out if you are ready to start UW.

What if I get a 205 on my first NBME and I start UW right away? You wouldn’t be
taking the most out of UW. In order to follow the academic mental process I explained in the
“How to use a Qbank” section you must have a baseline knowledge that allows you to think of
differential diagnosis by recalling several concepts. If you’re not ready, you would be reading
some questions while saying “what the hell are they talking about?” and then you would
randomly pick any choice only by guessing. That’s exactly what you shouldn’t do. That would be
a wasted question. And of course, after seeing the explanation you would say “wow! What a
stupid pick, it was obvious that I had to pick the other choice, now everything is so clear!” Of
course it’s clear! That’s why they call it “explanation”. But that is not your goal. You need to
read a question and be able to recognize the diagnosis/topic and to suspect which might be the
correct choice, what are the wrong ones and, most of the time, to find yourself between only two
possible answers.

First Aid + UWorld (3-4 months)

First of all, you must realize that these two resources are by far the most valuable ones for Step 1,
which means that the time you’ll spend using them will be the most valuable and influential for
your score. All you need to know in order to get a 270 is in FA and UW. Therefore, at this point
your life should have a big change. You’re now an Olympic athlete. Focus your 100% on this last
months. Remember this: you need to study as much as you need to rest. Nothing else! For your
body; eat and sleep (and, if possible, exercise) properly every single day. For your mind; rest
properly on the weekends (or at least on Sundays). Never: eat less or too much, sleep less or too
much, study 7 or more days in a row. You need 1 day off every week! I can’t stress this enough!
Off means zero hours of study during the 24 hours of that day. Trust me in this one!

Now back at study matters. First, you need to go to “How to use a Qbank” section and
read it again. I’ll wait for you … Done? Alright, let’s carry on.

How to use UW for Step 1:

• Rules: First, answer your block at the beginning of your day so you can review all the
questions during the rest of the day and you never have to leave questions to review for
the next day. Second, review every single question with FA. No matter how easy the
question was for you, go through all the steps described in the “How to use a Qbank”
section, which includes the extensive use of FA as your only Review Book.
• First 70% of UW: One untimed mixed block of 40 unused questions per day. No more,
no less. Spend the whole day reviewing it! If you finish before your day ends, it means
 you`re reviewing it too superficially. If one day isn’t long enough, you’re reviewing it too
thoroughly.
• 70-85% of UW: One timed mixed block of 40 unused questions per day. It’s time to set
the timer on. More about the timer will be explained in the “Final Weeks” section, but for
now focus on finishing the blocks under 60 minutes, just as the timer allows to.
• 85-100% of UW: One timed mixed block of 40 unused questions plus one timed mixed
block of 40 wrong or marked (used) questions per day. That is two blocks a day, which
you’ll answer one right after the other without pause (i.e. 80 questions in a row). The
review of the wrong or marked questions block should be quick, since you should focus
mostly on the used (repeated) questions (i.e. review thoroughly the wrong questions and
superficially the right ones). The review of the unused questions block should be as always
(i.e. every single question thoroughly). This will allow you to review both blocks in a day.
Why don’t you do all the unused questions first and then you go for the used questions?
Because you don’t want to get used to repeated questions, especially right before your
actual test, since, as you’ll notice, answering used questions requires less mental work
compared to unused questions. It feels easier, lighter. You’ll finish answering those blocks
in much less time. So, in order to redo all the wrong and marked questions, we start at
this point and by mixing them with unused questions we avoid losing rhythm or skills
required for a block of unknown questions.
• After 100% of UW: Two or three timed mixed blocks of 40 wrong and marked (used)
questions until you have done all the wrong and marked ones. Once you’re done with
that, your plan is completed. You’re ready and it’s time to go to the “Final Weeks”
section.
If you do UW this way, which I consider is the best, it shouldn’t take you less than 3
months.

Finally, I know I haven’t talked about doing UW twice or three times, neither have I done
so about when to take NBMEs and Self Assessments, and to decide whether or not you’re ready
for your Step 1. But please don’t worry, this will be clear in the next section.

Assessments: NBMEs CBSSA and UW Self Assessments (UWSA)

 • The NBMEs are numbered progressively as they are released. The #13 is the oldest one,
the #19 is the newest one. The newer the better.
• First Assessment: Which one? NBME 15. When? Right before starting UW. How?
Untimed. What will it tell me? Whether or not I’m ready to start UW.
• Second Assessment: Which one? NBME 16. When? At 70% of UW. How? Untimed.
What will it tell me? How much have I learnt by doing UW and how much more could I
improve? You start seeing the big picture of your progress and the real scores you can
aspire to get. It doesn’t change your conduct. It gives you important information, but you
shouldn’t take any decision based on this score. Remember that it doesn’t matter whether
you get a 260 at this point, you still need to finish your whole plan in order to make sure
you’re at your finest, at your 100%.
• Third and Fourth Assessment: Which ones? NBME 18 or 19 and UWSA-1. When? After
you have done 100% of UW. How? Timed. What will they tell me? Whether I have
reached my goal (target score), and if not, how far I am from it. Why two Assessments?
Because this Assessments will decide whether or not you go and take Step 1 within the
next weeks. Thus, in order to make sure the assessment score is reliable, you need to do
two instead of one, since by increasing the sample you increase the power of the study.
You will take both within the same week or so, and then you’ll calculate the average of
both. That average score (+ or – 10 points) is most likely the score you’ll get if you take
Step 1 within the next two or three weeks. Bear in mind that the scoring system of
UWSA-1 will give you a score around 10 points higher than the NBMEs. It’s not that
UWSA-1 is easier that NBME 18 or 19. It’s just the scoring system. So, you’ll subtract 10
points from your UWSA-1 and that will be your real assessment score which you will use
to calculate your average score (e.g. NBME 18 score: 240. UWSA-1 score: 254. Average:
240 + (254 - 10) / 2 = 242!

Then, at this point, what if I’m at or above my target score? Go to the “Final Weeks”
section.

And what if I’m below my target score? That’s coming up next.

Plan B: I finished UW and I’m still below my target score.

You completed your Plan A and still you’re not where you want to be. If you gave all of your
effort and were disciplined enough during all the steps throughout this plan, you’re probably
closer than ever to the highest score you can get, even if that means a score below your
expectations. However, you can’t give up! You must try to get closer to that target score, you
must give yourself a second chance, you must strive, and you must struggle and pursue that
dream even if it seems impossible!

What is Plan B? It is taking more time of your day for reviewing your weaknesses and the
rest of it for doing UW once again. Say, you will spend around three hours a day improving
specific topics you consider your weaknesses and the rest of the day you will be doing UW. You
can do one or two blocks a day. It depends on what score are you getting in those used (repeated
questions). If you’re getting 85% or above on each block of used questions (34 right questions out
of 40) you probably don’t need to spend so much time reviewing the right questions, so you can
do two blocks a day and focus your review time mostly on the wrong and marked questions. That
will allow you to review two blocks per day and to do again the 2400 questions in no more than 2
months. Nonetheless, if you’re getting below 80% on each block, you need to review thoroughly
each block, just as you did the first time (with new-unused question). This means you should
answer and review only one block a day at least during the first 50% of this second round of UW.
After that 50% you should be able to jump up to two blocks a day. In total, it should take you
around 3 months.

Then what? Only after having finished the totality of the 2400 UW questions for the
second time, you will take another NBME (18 or 19, since you should have done only one of
those at the end of your first round of UW) and the score you get here will be the highest score
you can get. After that NBME, you will do what you’ll find in the “Final Weeks” section.

STEP 2 CK

Before you start reading this section, if you haven’t read the “Step 1” section, please do it now.
There you will find important information that is equally useful for this section.

The main difference for the Step 2 CK preparation is that there isn’t a perfect Review
Book as there’s for Step 1. The “best” books are Master the Boards Step 2 CK (MTB2) and First
Aid Step 2 CK (FA2); both are equally incomplete and inaccurate, yet both are the best options
for you. Take a look at both of them before starting your study plan and pick the one you like
better.

Having said that, it’s reasonably obvious that UW gets now even more relevance for this
test. However, you still need to go through your Review Book, since you need the foundations for
a proper understanding of the dynamic and the content of the test. In other words: do not start
doing UW if you haven’t gone through your Review Book for at least one month.

Finally, I would like to share my experience about how I set my Step 2 CK study plan up.
Since the academic resources for this test are not as plainly defined as they are for Step 1, I
surveyed 15 IMGs that had gotten >250 in Step 2 CK about their preparation and what they
consider most important. The results were pretty consistent in the sense that all of them
recommended doing UW thoroughly and having either MTB2 or FA2 as a Review Book, and
none of the four people who had used Kaplan Books, Step up to Medicine Book, Kaplan Qbank
or DIT videos, recommended them at all. Also, all of them said the most reliable assessment was
UWorld Self-Assessment 1. They were divided regarding the use of NBMEs, with some of them
supporting the two most recent NBMEs and others none. Now, based on that information and
my personal experience, the following is what I consider the best study plan for Step 2 CK.

Pre-UWorld Review

This section is split in two according to how much time has passed since you took your Step 1
and what score did you get.

• Short Time (no more than three months) and above-average Step 1 score (>228).
These two things mean that you have strong and recent foundations. Therefore,
you don’t need to spend much time studying your Review Book before starting UW.
Nevertheless, make sure you spend at least one month during this section. Use the study
techniques I previously explained in the “Step 1” section, especially those for the “Kaplan
books” section. Only when you have reviewed 100% of the content of your Review Book,
you can start UW. Not before. Do not waste those precious questions.
• Long time (more than six months) and/or below-average Step 1 score (<228)
 Either of these two things mean that, before starting UW, you need extra time for
building strong foundations. How are you going to do that? By following the same
dynamic one follows for the Step 1 initial preparation.
You’re going to spend between two and three months reviewing the basic stuff
plus your Review Book. Whether you use Kaplan books, Step up to medicine, Kaplan
Qbank or DIT videos, it doesn’t matter. It’s all about getting the general and basic
knowledge for each subject. It’s about reviewing slowly and patiently every topic, focusing
on the understanding of the basic and most important concepts of each disease. As per
my opinion, I would recommend Kaplan books for this purpose, since they’re large
enough and up to date to cover the material you need at this point, and make sure you
have studied 100% of the content of your Review Book before going for UW. Once
again, use the study techniques I previously explained in the “Step 1” section, especially
those for the “Kaplan books” section.
Unlike the Step 1 preparation, you don’t have reliable assessments for finding out
whether you’re ready to start UW. The only one you’ve got is the UW Self-Assessment 1
which you want to save for the end of your study plan to see whether or not you’re ready
to take your test. Therefore, you must not get stuck in the “Pre-UWorld-Review” period.
You should follow it properly, but once done, you must go for UW.

UWorld + Review Book (MTB2 or FA2)

Part of this section is exactly the same as the “First Aid + UWorld” section for Step 1. However,
there’re several changes that are crucial for your Step 2 CK. Read carefully.

First of all, you must realize that this resource is by far the most valuable one for Step 2
CK, which means that the time you’ll spend using it will be the most valuable and influential for
your score. All you need to know in order to get a 270 is in UW. Therefore, at this point, your
life should have a big change. You’re now an Olympic athlete. Focus your 100% on this last
months. Remember this: you need to study as much as you need to rest. Nothing else! For your
body; eat and sleep (and, if possible, exercise) properly every single day. For your mind; rest
properly on the weekends (or at least on Sunday). Never: eat less or too much, sleep less or too
much, study 7 or more days in a row. You do need 1 day off every week! I can’t stress this
enough! Off means zero hours of study during the 24 hours of that day. Believe me in this one!

Now back at study matters. First, you need to go to “How to use a Qbank” section and
read it again. I’ll wait for you … Done? Alright, let’s carry on.

How to use UW for Step 2 CK:

• Rules: First, answer the questions at the beginning of your day, so you can review all of
them during the rest of the day and you never have to leave questions to review for the
next day. Second, review every single question with your Review Book (MTB2 or FA2).
No matter how easy the question was for you, go through all the steps described in the
“How to use a Qbank” section, which includes the extensive use of your Review Book.
Third, you will copy everything you find in UW that is lacking in your Review Book,
especially the tables and flowcharts.
• Strategic tip: For each question of UW and your actual Step 2 CK, when you start
reading it you should always highlight the patient’s primary information (sex, race, and
age) and his/her main complain. This information is usually given in the first two lines of
the vignette. Next, keep reading the stem and right before reading the actual question,
stop and go back and read again the highlighted patient’s primary information and
his/her main complain. Then, and only then, you read the question and try to answer it.
Why? Because the Step 2 CK questions are very long and extremely confusing. So
many things pass through your mind while you’re reading the whole vignette and by the
time you get to the question, your differential diagnoses and potential answers are
supported mostly by what you read during the last half of the case stem. And, as you’ll
see, the distractors you encounter as you read the case will make you focus on some
specific points that not necessarily will take you to the right answer. Instead, the
distractors will make you forget about that first line of the case, which happens to be
(most of the times) the patient’s primary information and his/her main complain.
• First 60% of UW: One untimed mixed block of 40 unused questions per day. No more,
no less. Spend the whole day reviewing it! If you finish before your day ends, it means
you`re reviewing it too superficially. If one day isn’t long enough, you’re reviewing it too
thoroughly.
 • 60-85% of UW: One timed mixed block of 40 unused questions per day. It’s time to set
the timer on. More about the timer will be explained in the “Final Weeks” section, but for
now focus on finishing the blocks under 60 minutes, just as the timer allows to.
• 85-100% of UW: One timed mixed block of 40 unused questions plus one timed mixed
block of 40 wrong or marked (used) questions per day. That is two blocks a day, which
you’ll answer one right after the other without pause (i.e. 80 questions in a row). The
review of the block of used questions should be less extensive by reviewing thoroughly the
wrong questions and superficially the right ones. The review of the block of unused
questions should be as always (i.e. every single (wrong and right) question thoroughly).
This will allow you to review both blocks in a day.
You would be wondering why you don’t do all the unused questions first and then
you go for the used questions. Because you don’t want to get used to repeated questions,
especially right before your actual test, since, as you’ll notice, answering used questions
requires less mental work compared to unused questions. It feels easier, lighter. You’ll
finish answering those blocks in much less time. Therefore, in order to redo all the wrong
and marked questions, we start at this point and by mixing them with unused questions
we avoid losing rhythm or skills required for a block of unknown questions (i.e. your
actual test).
• After 100% of UW: Two or three timed mixed blocks of 40 wrong and marked (used)
questions until you have done all the wrong and marked ones. Once you’re done with
that, your plan is completed. You’re ready and it’s time to go to the “Final Weeks”
section.
If you do UW this way, which I consider is the best, it shouldn’t take you less than
3 months.

Assessments: NBMEs and UW Self Assessments (UWSA)

There’s not much relevant information to mention here given the fact that the only reliable
assessment is the UWSA-1. The only advice you should follow strictly is this one: take the
UWSA-1 only when you have completed 100% of UW. Not before. The other assessments are
optional and not very important for your study plan or test date. Take one or two as you go
through UW. Say, NBME 6 or 7 at 50% of UW, and UWSA-2 at 70% of UW. However, the
date of your test should be placed three or four weeks after completing 100% of UW according to
your study plan. And once you take the UWSA-1 you either confirm your study plan and go
ahead for that date or move it forward if you haven’t reached your target score.

Then, at this point, what if I’m at or above my target score? Go to the “Final Weeks”
section.

And what if I’m below my target score? That’s coming next.

Plan B: “I finished UW and I’m still below my target score”

You completed your Plan A and still you’re not where you want to be. If you gave all of your
effort and were disciplined enough during all the steps throughout this plan, you’re probably
closer than ever to the highest score you can get, even if that means a score below your
expectations. However, you can’t give up! You must try to get closer to that target score, you
must give yourself a second chance, you must strive, and you must struggle and pursue that
dream even if it seems impossible!

What is Plan B? It is taking more time of your day for reviewing your weaknesses and the
rest of it for doing UW once again. Say, you will spend around three hours a day improving
specific topics you consider your weaknesses and the rest of the day you will be doing UW. You
can do one or two blocks a day. It depends on what score are you getting in those used (repeated
questions). If you’re getting 85% or above on each block of used questions (34 right questions out
of 40) you probably don’t need to spend so much time reviewing the right questions, so you can
do two blocks a day and focus your review time mostly on the wrong and marked questions. That
will allow you to review two blocks per day and to do again the 2400 questions in no more than 2
months. Nonetheless, if you’re getting below 80% on each block, you need to review thoroughly
each block, just as you did the first time (with new-unused question). This means you should
answer and review only one block a day at least during the first 50% of this second round of UW.
After that 50% you should be able to jump up to two blocks a day. In total, it should take you
around 3 months.
 Then what? Only after having finished the totality of the 2400 UW questions for the
second time, you will take another assessment (NBME 6 or 7, or UWSA-2) and the score you get
will be the highest score you can get. After that assessment, you will do what is explained in the
“Final Weeks” section.
 You go the way to your greatness; here shall no one steal after you! Your foot itself has effaced
the path behind you, and over it stands written: Impossibility.

—Friedrich Nietzsche, Thus Spoke Zarathustra

FINAL WEEKS

KNOWLEDGE

Around 70% of your test will be about High Yield (HY) topics. If you want to get an average
score you must, at least, master that 70%. If you want to get an above-average score you must
master that 70% HY plus the remaining 30% Low Yield (LY) content. I know everybody wants
an above-average score, but my point is that one thing must precede the other.

Taking as starting point the regular schedule of preparation for an average IMG, around
3 or 4 weeks before your test day (TD) you must have read, studied, reviewed and memorized
most of the content found in your review material as it habitually is FA, MTB and UW.
Nevertheless, and given the circumstances at this point of your preparation, your study strategy
should be changed and adapted in order to optimize one of the most important skills for your
actual TD; the easy and rapid retrieval to all the content you have been storing during these last
months. I know you probably master most of the material, you’ve got it on your solid long-term
memory slot. Nonetheless, there’s a significant amount of that solid knowledge that right now is
neither easy nor rapid accessible for you. Perhaps you haven’t reviewed it lately, say, the last
question you get about it was 4 or 5 weeks ago, or perhaps you mastered it and memorized it so
well that you haven’t taken a look at that page recently, even if you got some questions about it
lately. Whether you like it or not, it has been fading away, and, unless you do something, it will
have considerably gone farther by the time of your TD.

The take away: It is time to leave aside the “studying-memorizing new material” strategy
and replace it by the “re-view re-fresh all, old and new, HY material”. It is not time to get new
knowledge, especially if it is not HY material. It is time to review all the HY material, to identify
your weaknesses and to focus only on that material. Make sure you read carefully 100% of your
material (Review Book and UW notes) and write down every single HY topic you find difficult to
recall, since those topics are the only ones you will review once again before your TD. It is also
time for memorizing all those formulas and long lists of unrelated facts. It is time for cramming.
Doing it properly, and spending around 8 hours per day, it shouldn’t take you less than 5 days.

CONDITIONING

“Train as if you were competing and you will compete like you trained”

I know it is impossible to do 7-8 blocks a day during all your preparation, but it doesn’t
mean you can’t get an optimal conditioning that allows you to end most of the blocks around 50-
55 minutes and maintain your performance throughout the whole day, especially in the last 2-3
blocks. What I am telling you is that it is totally possible not to give points away due to time, post-
prandial somnolence and fatigue issues.

The rules you set for your TD regarding the timing, your breaks and your meals must be
decided based on your personal experience and not on what your friends or I say. You must go
on simulation for some days in order to try different combinations, particularly breaks and meals,
and to be able to compare and to pick the one that suits you better.

Timing

Please do not train yourself allowing you to use 60 minutes per block. During the real test you
will be scared and you will face different types of questions, so don’t expect to be as fast as you
were when sitting in your comfortable usual study place without any comparable amount of
pressure and feelings. Please do train yourself allowing you to use no more than 50-52 minutes
per block.

Set about two time-checkpoints that allow you to evaluate your pace and take action
before it’s too late. It’s not about going as fast as possible. It is about going at the same pace you
practiced. The checkpoints will allow you not to lose focus by looking at the time when feeling
that you’re spending too much time in a question or when too nervous or scared. If you are three
or more minutes ahead of your checkpoint, you’re going too fast. Stop and breathe deep and
slowly for one minute, tell yourself “I’m doing great, I’m killing it, just slow it down a little bit”. If
you’re behind, take one deep breath, fill yourself with confidence, and carry on! That’s the point
in doing it. You correct yourself before it turns into lost points.
Breaks

Please do not do two or three blocks without stopping in between. Please do take at least three
minutes between every block, even if you don’t leave the room. For those small breaks in front of
the computer: Breathe deep and slowly, fill yourself with confidence, believe in what you’re doing
even if the block you just did was tough. You still have some revenge ahead.

Please do not rush the end of your test by not taking all of your remaining break time.
The one before the last block. Even if you feel super energized and confident. Please do take all
of your remaining break time. Even if it’s 30 or 40 minutes. Trust me in this one, that time is
harmless. Fatigue is not. You do need that time!

Food

Please do not eat like you eat every day in your life. You do not take the step 1 or Step 2 CK
every day! Please do eat and drink as less as possible. Preferably fast digesting carbs. A little of
hunger won’t do any harm, but a heavy postprandial somnolence will definitively decrease your
performance. I can’t stress this enough! Once you have finished, you will be free to eat 260
Chipotle bowls if you want.

SIMULATION

Please go on at least three simulations. Preferably a few days before TD.

Simulation means

• Go to bed the night before and wake up at exactly the same time you will for your TD.
• Get exactly the same breakfast you will for your TD.
• Wear exactly the same clothes you will for your TD.
• Do not take more than 60 minutes for breaks. In the actual test, the remaining time you
have left in every block, once finished, will be added to your break time, but remember
that in the actual test it will probably take you longer to answer every block. So do not
trespass those 60 min. Do not simulate based on assumptions.
 • Every day try different combinations of breaks and meals.
• How do you know what really suits you better? The feeling after each block might tell you
something, but it’s 100% subjective. The scores and the remaining time after each block,
however, can give you objective information. I myself find the remaining time after each
block as the most reliable index of fatigue. Take into account both sources and make your
choice.
• The strategy you pick is the one you will strictly follow in your TD. Please do not change
it in your TD, since stress, anxiety and fear don’t match good conclusions. This is exactly
what you prepare for, to perform as your best, not as your feelings when nervous and
scared.

FINAL TWO WEEKS PLAN

• No more NBMEs. No more Self assessments.

• From the Day 15 on you will go to bed and wake up at exactly the same time you will for
your TD. During the last week, try to eat as much similar as possible.
• Day 15 through Day 9: 7 days total.
o Read all your review material (FA, MTB, UW tables, UW notes), focusing mostly
on HY topics.
o Identify your weaknesses (only on HY material) and write them down in a piece of
paper.
o Once again. Doing it properly, and spending around 8 hours per day, it shouldn’t
take you less than 5 days.
o Just to keep on track, your rhythm, do two blocks every day and review
superficially only the wrong questions. It shouldn’t take you more than 2 hours. At
this point, you must have done all UW, including the wrong and the marked ones.
• Day 8: Rest! Do not touch any book or notes. Keep your mind and body busy with active
and enjoyable activities. Do not just stay in bed or at home chilling.
• Day 7 through Day 5: 3 days total
o Simulation: 7 and 8 timed blocks of 40 questions for Step 1 and Step 2 CK,
respectively. Three days in a row, so you can easily compare and decide what
 strategy suits you better. Of course you will use UW and the 120 free USMLE.org
questions available for both Step 1 and Step 2 CK.
o Whether you review the answers or not, it’s not relevant. You will be so tired after
each simulation that whatever you read, it will not stick.
• Day 4 through Day 2: 3 days total
o Review and do everything you can in order to memorize the HY weaknesses you
wrote down on that piece of paper when you reviewed your guide material.
o Here you could find very useful fast memorization devices such as “memory
palaces” or “person-object-action”. Take a look at them on Google.
o Just to keep on track, your rhythm, do two blocks every day and review
superficially only the wrong questions. It shouldn’t take you more than 2 hours.
• Day 1: Rest!! Do not touch any book during those 24 hours. Keep your mind and body
busy with active and enjoyable activities. Do not just stay in bed or at home chilling.
Please trust me in this one, do not study on Day 1. Not a single minute. You need this rest
time!! I really can’t stress this enough!
• DAY 0: Wake up and destroy the USMLE!! Stick to the plan and you will succeed!!

Thank you for having given me the opportunity to help you!

“… and she does so much good! Ask everyone! Everyone knows her!”
“Perhaps so,” said the prince; “but it’s better when
one does good so that you may ask everyone, and no one knows.”

—Leo Tolstoy, Anna Karenina