Learning for the USMLE: 4 Steps to Success


Learning at the level required by the USMLE involves doing a set of processes in sequence. You must be made aware of, and then, work though this process. This is important so I’ll repeat it. Effective study is not about doing a lot of one thing, but doing a set of thing in the right sequence.

  • Highlight: Selecting the material to be mastered

Study begins by a series of decisions. First, what material to study? Second, what to focus on within that material? If, for example, you select Becker (Disclosure: I work with Becker) to help with your exam preparation, you have already made your first choice–Becker provides the study materials. I want to caution you about overloading yourself and trying to study the Becker material and another source simultaneously. More sources are NOT better. Find a single source you can believe in and then, master that sources. Using multiple sources usually leaves students feeling overwhelmed. Having a reference book on the side for detailed explanations makes sense, but the your selected study material should be your sole focus.

Teachers who help you prepare for your USMLE can help you make the next choice about what to focus on within the study material you have selected. Some students obsess about mastering each and every little detail without regard for relevance. Others, skim the surface, picking up a stray fact here and a fact there. Your teachers are your guides and can help you find the middle ground by telling you what is worthy of more attention and what is not. As you listen to lectures, as you talk with your teachers, the material they emphasize provides you direction as to what is most essential content AND what can be safely ignored. The role of your teachers is not just to cover material, but make you more efficient by underlining what matters more.

We call this step “Highlight” because this is when you may you highlighter pens. As you lecture listen to lectures by your faculty you should be underlining key material, making marginal notes, and marking annotations about what you need to return to for additional review.

  • Repetition: Getting content into memory

Once you have highlighted the content  must you learn, you need to commit this content to memory. The human brain, although complex, has a simple functional imperative—it remembers content that recurs. Getting content into memory is, thus, a simple process of repetitive exposure.

Part of this exposure occurs during the lectures and discussion you have with our teachers and fellow students. I encourage students to look over the content to be covered each day prior to the lecture (Preview), attend lectures and listen to the teacher’s illustrations and guidance (Participate),  and then go back over the essential materials in the evening after each day‘s lectures are completed (Process). These multiple exposures provide the needed repetition to get your brain to pay attention and remember.

Most students will need to review core material one or two times outside of lecture. The number of repetitions required, of course depends of the student’s previous preparation and learning capacity. Two passes over most material (Lecture and then Review) are all that is required for most students. For more complex material, three repetitions may occasionally be necessary.

Refrain from mindless, rote reading of content more over and over again. Simply reading content again, without thinking about what you are reading is unlikely to be successful. Effective repetition for retention requires thinking, processing what they are reading, not merely reading the words just to read them. The difference, as one student once described it, is between “ingesting” and “digesting” the material. Ingesting is just reading for the sake of reading.  Digesting means reading with real comprehension.

  • Recall: Accessing memory as needed

Repetition gets the content into your head. But to do well on their exam, you need to be able to access the content when you need it. Getting the content into your head is not enough.  You also need to be able to get it out again!

This is the key part of the study process many students neglect. As a consequence, they often report sitting in the exam, knowing that they studied the content be presented in an exam question, but being unable to call the needed content to mind.

Recall is fostered by creating an internal index that tells the brain where to find the desired material. Part of this process happens when we sleep. (So, it is essential that you get enough sleep as you study!) Part of this indexing happens whenever the student actually does something with the content they have learned. Talk to yourself and to fellow students about what you are learning. These discussions, mental and actual, are readily recalled on exam day.

Students sometimes think that if they do not have their nose in a book they are not learning. Recall is not about reading the book again, but about doing something with the content. Talk to yourself while walking or driving. Make outlines, draw pictures and construct graphs. The more of this you do, the more readily available will be the content on the day of the exam when you need it the most.

A nice rhythm for study is: read a page once looking for the key idea, read it again to fill in details, and then the third time, put your hand over the page and tell yourself what are the essential issues on that page. This last recall step is the essential element that separates the students who study hard, from the students who study hard and have good score to show for it.

  • Practice: Behavioral habits for handling the exam. Knowing does not equal showing.

Once you have committed key content to memory and once you have spent some preliminary time facilitating recall of that material, you are ready to practice on questions. Questions are NOT the best way to learn content, but they are the ONLY way to learn and practice the questions answering behaviors and strategies that students will need the day of their exam. You must learn correct behaviors and practice them so that they become routine. Only then can you show what you have learned under the time pressure imposed by the USMLE format.

Here is a quick summary of good question processing behaviors:

  1. Read the case presented in each question only once.
  2. Predict what the correct answer will be before looking at the options.
  3. Make a choice and live with it. Move on to the next question.
  4. Do not change answers once they are selected.
  5. When reviewing results, look at why you got a question wrong.
  6. If questions reveal deficiencies in the recall or understanding of essential content, return to your core study materials to review that content once again.

Remember, you do not do questions to get a score, but to 1) learn and hone question answering behaviors and to 2) get guidance as to material you need to go back and review again.

What you do when you study should change as your exam becomes closer and you gain more familiarity with the material. You job is not just to stuff your brain with facts, but to understand the content you study, know why it matters, be able to access it quickly on exam day and become adept at the process of delivering the information to the questions you will face on exam day.

The days of being a student are over. The time to become a physician has come. Learn to think like a physician and you are well on your way to being able to prove on the USMLE that you are one.

Steven R. Daugherty, Ph.D.




Combining Content in Context: USMLE thinking


The thought processes required on the USMLE are different than those required on most medical school exams. The content you need to know is the same. But the way you need to think about that content, and how you will use that content in your exam, requires some mental reprogramming.

On medical school exams, recognition and paired association are the keys. A typical exam item presents a concept in the question stem and asks you to select the proper association from the presented choices. If you have studied sufficiently so that seeing a particular symptom reminds you of a disease diagnosis, or seeing a particular disease reminds you of the commonly used pharmacology, you will get the question correct. When you see “butterfly rash: you think “Lupus”.

You train yourself for these association questions by repeated exposure and memorization—going over the pairs and patterns over and over until you are programmed with the appropriate responses. In essence, questions on medical school exams are mostly are free association exercises. You get them right when you have trained yourself to have the associations your professors want you to have. As long as your associations are those of the faculty, you will do very, very well. You prove to the professor that you have mastered the required content by giving the required responses.

The USMLE wants more out of you. For the most part USMLE questions writers assume that you already possess the basic mental associations. They assume that the medical school has done its job. Their task is to see if you are ready for the next level. USMLE questions are not aimed at what you know, but are framed to see if you can apply what you know in a series of presented problem scenarios. Knowing is not enough, you have to be able to DO SOMETHING with your knowledge.

Few physicians would argue with this goal. The job of the medical practitioner is not to serve as a human reference book, but to make decisions, to take actions based on what they observe combined with what they know. This is what the USMLE tests: how you take in information and how you are able to reason with the information you collect.

Context is the key to understanding the information presented to you in a USMLE question. Particular facts mean different things in different circumstances. Meaning comes as much from surrounding data as from the presented detail itself. Fatigue, reported by a patient, may be an important symptom or merely the result of too little sleep. The meaning rests with the full set of symptoms and life circumstances presented. Single symptoms are ambiguous. Context provides the pieces to let you see the essential presented patterns.

Combination is the key process for the problem-solving required on USMLE questions. You must combine the information presented in the question with the information in your own head. The patterns you see plus the patterns you remember give you the insight to reason though to the best answer. If the question presents a symptom constellation, you must have the knowledge in you head to recognize the disease that this signifies. Recognizing a pattern in the question, but not remembering what it signifies means that you will not get the question correct.

Answer each USMLE question by first deciding, “What is given in the question?” and the deciding, “How does that relate to what you know?” This process, not simple association is the solution you seek. Content and combination result in the clarity you need to pick the best answer.

A detailed walk thought this process can be found in an article I posted in cooperation with Dr. Philip Tisdall on www.usmlethought.com. Look under the heading “Handling USMLE Questions.” Learning the mental steps to understanding USMLE questions is as important as mastering content details.

Steven R. Daugherty, Ph.D.