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The ONLY Video You Need to Pass the USMLE Step 1 in 2026 — Transcript

by Alec Palmerton, MD · 8,772 words · 1,253 segments · language en · Watch on YouTube

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0:00If 100 Uled questions a day is your plan
0:02for passing step one, you're either
0:04wasting time and money reinforcing bad
0:06habits or you're actively setting
0:08yourself up to fail and you don't even
0:10know it yet. Here's the thing. 100 old
0:12questions a day is the right solution
0:14for some problems, but it's not the
0:17right solution for every problem.
0:22Let me tell you about a student that I
0:23worked with. We'll call him Jay to
0:25protect his privacy. He failed step one.
0:27He was so depressed that he couldn't get
0:29out of bed. I still remember his mother
0:31literally had to stage an intervention
0:33for him. She literally dragged him from
0:36his bed to his meeting with us. Now,
0:38before you think, oh god, he should have
0:40just done 100 questions a day, let me
0:42tell you what he actually did. First of
0:43all, he did the whole let's just do 100
0:46questions a day thing. Second, he did
0:48NVMememes, like all of them. And he had
0:50done a ton of ANI, like all the pre-made
0:52cards, and his scores on his NVMEs were
0:55actually quite good. He was scoring like
0:57you know 60s and he still failed his
0:59exam. Now for someone who had done
1:01everything that you're supposed to do,
1:03how is it that he failed? This is what
1:04we discovered. He was using the right
1:07materials in the wrong way. He was
1:09cramming, not really learning. He was
1:10memorizing all the pre-made donkey ducks
1:12without really understanding. His NBME
1:14scores looked okay on the surface, but
1:16it was really fragile because any time
1:18that they changed what it is that they
1:19were asking or the way that they were
1:21asking it, he would struggle because he
1:23could memorize the answers to questions,
1:25[music] but would struggle in novel
1:27situations. It was as if he'd memorized
1:28the answer key rather than understanding
1:30the process. When he got to test, the
1:32questions were slightly different and
1:34everything fell apart. So, what we did
1:36is that we changed his approach, not his
1:39resources. It was the same UWorld, the
1:41same first aid, the same an
1:45method. Within 2 months, he scored a 92%
1:48on his practice NBME. Now, for context,
1:50that would be like the top 3% when step
1:53one was actually scored. Nowadays, you
1:55never see people score a 92% on their
1:57NBMES, and this was an unused NBME that
2:00had come out in the meantime. He passed
2:02step one. He crushed his shelf exams,
2:04and he did substantially better on step
2:06two. Ultimately, he matched into
2:07urology, one of the most competitive
2:09specialties out there, despite the fact
2:11that he'd failed step one. So, what did
2:13he actually change so that he could
2:15transform his approach and score
2:17substantially better on his retake and
2:19completely change the trajectory of his
2:21medical career? It comes down to these
2:2310 steps. Step number one is to know in
2:2624 hours if your approach is going to
2:28work or not. Most students wait until an
2:30NBME to find out if their studying is
2:32working. Now, conservatively, that might
2:34be a week or probably longer and
2:36sometimes months of potentially wasted
2:39effort because you're waiting all of
2:41that time when you change something. The
2:42issue is that if you're waiting for your
2:45next NBME, which might be weeks or
2:46months after, you aren't going to know
2:50for weeks or months whether your setting
2:52is actually working. In addition to
2:54that, if your NBME doesn't go up, you
2:56have no idea what really went wrong,
2:58right? Maybe it was the number of
2:59questions that you were doing. Maybe it
3:00was the fact that you were doing this
3:02set of resources. Maybe it was that you
3:04were doing this set of lectures over
3:05this set of lectures. Maybe it was the
3:07fact that you were taking notes. Maybe
3:08it was these pre-made Anki cards that
3:10you found. You're changing so many
3:11things at one time. And the time it
3:14takes for you to know whether it's
3:15working or not is so long that it just
3:17becomes this really confused mess of
3:19like I have no idea what's going on and
3:21I don't know how it is that I need to
3:23[music] fix my efforts so that I can get
3:24a higher score. It's like hitting a
3:26tennis ball and not knowing where it
3:27went for 2 weeks. You're never going to
3:28improve that way. The solution is what
3:30we call the 80% mastery method. What you
3:32want to do is you want to pick a single
3:33subtopic. I recommend coronary artery
3:35disease because it's relatively clean
3:37and self-contained. Meaning I don't have
3:39to understand other things in order to
3:41understand that if you block a coronary
3:43artery then it's going to cause you know
3:45eskeeia and eventually necrosis of the
3:48muscle that is being fed by [music] that
3:49coronary artery. Right? It's very simple
3:50and self-contained. Then you want to
3:52study the entire fit section on that
3:54topic. I highly recommend that you make
3:56flashcards so that you don't forget it.
3:57Then you want to test yourself using 10
3:59consecutive unused Qbank questions on
4:01that particular subtopic. I like UWorld,
4:03but there's a lot of other QBanks out
4:04there that I think can do the same
4:06thing. Your goal is is that within 24
4:08hours, you want to get 80% or more
4:10correct on those questions. Why do we
4:12recommend 80% and not 70 or 90 or you
4:15know because 60% is fragile. It's simple
4:17math. If you're at 50% right now overall
4:19and you get half of the content to 80%,
4:22now your average becomes at least 65%.
4:2565% overall gives you approximately a
4:2795% chance of passing step one. If I
4:29want to increase that further, then I
4:31just have to add more subjects that I
4:33would be getting at 80% and I can just
4:35continuously increase my score. Plus,
4:3780% gives you a buffer so that if you
4:39forget stuff, if you have a bad day, if
4:40you've got test day [music] nerves, it
4:42still gives you that margin for error in
4:45case that something happens. Now,
4:46instead, if you only get 60% on
4:48something that you just studied, what
4:50happens when you forget some of it? The
4:52other issue is is that if life happens,
4:53right? Like let's say that your dog dies
4:56or your grandmother passes away or you
4:59get really really stressed the night
5:00before and you can't sleep. Then those
5:02things can cause your score to go down
5:04temporarily. The issue is that if you're
5:07just skating by, if you're just barely
5:09at the passing line, then when those
5:11things happen, then your score can drop
5:12and you can actually fail your exam.
5:14Right? We get a lot of consultations
5:15from people who just were barely passing
5:18and then they something happened on the
5:20day of their exam and then they didn't
5:22have enough of a buffer and then they
5:23ended up failing. The more subjects that
5:26you can add that are at 80% and the
5:28greater the overall score that you have
5:30going into [music] your test, the
5:31greater the likelihood that you're going
5:32to be resilient against all sorts of
5:34difficulties. You might be asking, "What
5:36if I don't hit 80% on that first
5:38subject?" The answer is don't move on.
5:40You know that there's something wrong.
5:41If you can't study something and get at
5:43least 80% on it in a day or two, there's
5:46probably something wrong and it means
5:47that you need to fix it now rather than
5:49wasting weeks of time studying for
5:52things and not doing it in the right
5:53way. If you only take one thing away
5:55from this video, remember that you
5:56should know if your studying is working
5:58in a day, not a month. But what exactly
6:00should you be studying when you go
6:01through that subtopic? That is step
6:03number two. Step number two is master
6:05the whole page, not just what you
6:07missed. If you want to maximize your
6:08chances of passing step one on the first
6:09try and building the foundation to do
6:11much better on your shelf exams and step
6:13two, be sure to sign up for a 14-day
6:15free course in the description where you
6:16can learn both the content and the
6:18approach to how to maximize your scores
6:20on [music] these exams in the least
6:21amount of time. This is probably the
6:23biggest mistake I see is that you need
6:25to master the entire subject or system
6:28or page of the thing that you're trying
6:29to learn, not just the one sentence or
6:32fact that you got wrong. There's a lot
6:33of people that do a block of questions
6:35and let's say that you miss a question
6:36on mitro stenosis. What a lot of people
6:38will do is they're just going to learn
6:39that one fact like if they're doing an
6:41they might make one card on that one
6:43fact or they'll write it in their UWorld
6:45journal or something like that and then
6:47they'll move on hoping that somehow
6:49magically the rest of all of the
6:50valvular heart diseases are going to go
6:52up or that if they do that enough and
6:54they do their 100 UWorld questions a day
6:56that their score is just magically going
6:58to increase. The issue is is that 99% of
7:00people who don't see their scores go up
7:02fast enough aren't doing [music] this
7:04one thing. That one thing is that when
7:06you miss a question on mital stenosis,
7:08don't just learn that one fact. Instead,
7:10go to something like first aid and find
7:12the entire section that that came from.
7:15So in this case, it would be valvular
7:16heart disease. Then you want to learn
7:18all of it. Mitro stenosis, mitro
7:20regurgge, aortic stenosis, aortic regge,
7:22tricuspid, everything. and not just the
7:25facts, but also learn how to read the
7:27graphs, understand what the pressure
7:28differentials are. As you're doing this,
7:30you want to make flashcards on the
7:31entire section, right? Which might be
7:33two, three, maybe four pages. The reason
7:35for this is that the students that make
7:37cards on the entire first aid page
7:39actually move faster through the
7:41material. Why is that? Because they're
7:43anticipating questions that they're
7:44going to miss, not just reacting to the
7:46ones that they already got wrong. So
7:48remember, master the entire page or
7:50pages of the thing that you just got
7:52wrong, not just the sentence that you
7:54missed. So now that you're learning the
7:55whole section, you need to make the
7:57right kinds of Anki flashcards. That's
7:59step number three. Step three is use the
8:02two card types that make forgetting
8:03impossible. Most flash cards are
8:06actually useless. If anything, they
8:08might even be less than useless because
8:10they can make it even harder to apply
8:12information on the USML. Examples of bad
8:14cards are things like isolated facts
8:16with no connections. For example,
8:18something like what is infective
8:19endocarditis, and you just memorize the
8:21definition, but you can't actually apply
8:22it. There are tons and tons of pre-made
8:24decks out there that give you exactly
8:25this kind of information. The challenge
8:27is is that for medical school exams,
8:30which are largely exams of recall, where
8:32you can just regurgitate facts [music]
8:33and you can do just fine, those decks
8:35can do actually quite well. For the
8:37USMLES and shelf exams and even board
8:39exams like the ABIM, right, for the
8:41internal medicine boards, they ask you
8:43to apply information, not just
8:44regurgitate [music]
8:45it. Remember, if you're just memorizing
8:46words without understanding them, you're
8:48wasting your time. As an aside, I
8:50realize that there are lots of people
8:51who are going to show up and say, "No,
8:53but I have a friend who just memorized a
8:55bunch of words and they ended up
8:56passing." Or, "All I did was just
8:58memorize a bunch of random facts and I
9:00still passed my exam." That might be
9:01true, but I would argue that you're
9:03actually succeeding despite that
9:05approach, not because of it. It's very
9:07obvious when you talk to people that
9:08write questions for the NBME, that are
9:10writing questions for step one and step
9:12two and shelf exams, that they want you
9:14to actually know how to apply
9:15information, not just regurgitate it.
9:17And a lot of the people that are
9:18succeeding [music] using those cards are
9:20often times finding other ways to learn
9:22how to apply the information. and
9:23they're using those decks as [music] a
9:25way of just learning the facts and
9:27memorizing those things that they would
9:29otherwise have a hard time remembering
9:30themselves. So, if you actually want to
9:32understand how to apply and retain
9:34information, [music]
9:35there are two types of cards that work
9:37really well for this. The first is a
9:39concept card, which is how to master the
9:41why of something. So, instead you might
9:43say something like infective endocritis,
9:45use the pathophysiology to explain what
9:47you might see on an opthalmologic exam,
9:49right? You're looking for something like
9:50splinter hemorrhages. What this is doing
9:52is is that it's forcing you to
9:53understand the mechanism and the
9:55consequences of that mechanism, not just
9:57memorizing some sort of random fact. So
9:59another example would be epidural versus
10:01subdural hematoma. Instead of memorizing
10:03that epidural is lensshaped, instead you
10:06can say epidural versus subdural
10:07hematoma, use the pathophysiology to
10:10explain which presents faster and why.
10:12An epidural hematoma because it's
10:13arterial is going to have a higher
10:15pressure. Therefore, the bleed is going
10:17to be more rapid, which means it's going
10:18to present much more quickly. So a
10:20subdural hematoma comes because of a
10:22venus bleed. This is a lower pressure
10:24and as a consequence the blood is going
10:26to expand much more slowly and the
10:28presentation is therefore going to be a
10:29lot more gradual if even noticeable at
10:32all. The second kind of card that can
10:33transform your approach is what we call
10:35a pathophysiological guard. Now this is
10:37a term that we came up ourselves. If you
10:39look for this you're probably not going
10:40to find anything except for [music] what
10:42it is that we've written about it. The
10:43purpose of this is to try to train your
10:44pattern recognition. Have you ever
10:46gotten a question wrong where you
10:48realize, wait, I didn't even consider
10:50that diagnosis as a possibility? Right?
10:52The answer was infective endocarditis,
10:54but I didn't even consider infective
10:56endocarditis in my differential as I was
10:58reading through the vignette. Period.
11:00This is what a PC card will help you
11:02solve. Let me give you an example. So, a
11:0346-year-old man presents with several
11:05weeks of fatigue, low-grade fever, and
11:06unintentional weight loss. He now has
11:08new leftsided weakness. Exam reveals a
11:10new holysic murmur, splinter
11:12hemorrhages, and pitikia over the lower
11:13extremities. Labs show normacyic anemia
11:15and elevated creatinine with hematia. At
11:17first glance, this looks like maybe five
11:19different problems. You've got clear
11:21signs of infection, right? He's got
11:22fever. He's got fatigue. He's also got a
11:24stroke. He's got this new left-sided
11:26weakness. He's also got kidney problems.
11:28He's got elevated creatinine and
11:30hematia. And then there's this anemia
11:32and heart murmur. Many students panic in
11:34this and they're like, I don't even know
11:35what system I'm in. What am I supposed
11:37to do? But if you've made a PC card on
11:39infective endocarditis, you can see that
11:41there's actually one process that
11:43connects all of these different things.
11:45The chronology would look something like
11:46this. You know, bacteria that leads to
11:48vegetations that form in the valve.
11:50Those lead to embey that break off and
11:52that leads to the stroke. Plus, you can
11:53get immune complex deposits that are
11:55going to cause the kidney damage which
11:56leads to chronic inflammation. The
11:58chronic inflammation can lead to fever,
11:59weight loss, anemia disease, and
12:02ultimately valve destruction that's
12:03going to lead to the new murmur. There's
12:05one disease, one phenology, and
12:06everything connect. That oh, that oh my
12:09god moment where everything suddenly
12:11makes sense. That's what PC cards are
12:13training you to do. That's why students
12:14who use them say it feels like legally
12:16cheating on their test. In our program,
12:18we teach students how to do this. And we
12:20have a program that will generate PC
12:22cards for you and give you feedback on
12:24ones that you make. Even if you're not
12:25in our coaching program, the principle
12:27works for anyone. But making great cards
12:29doesn't matter if you forget them 2
12:30weeks later. That's step four. Step four
12:32is never forget what you learn. If
12:34you're getting 80% but you're forgetting
12:36what it is that you're learning, none of
12:38it's going to matter because you're
12:39going to be back to 50% [music] in just
12:40a week or two. Retention ultimately is
12:42what's going to let your score compound.
12:44Remember, if you can hit 80% and you
12:46never forget it, you will continue to
12:48keep [music] stacking points. However,
12:50if you forget half of what you learn,
12:52you're going to be running on a
12:53treadmill and studying forever. Ani is
12:56free and it works super well, but most
12:57people use it wrong. I'm going to walk
12:59through a few key settings that can help
13:00you transform the way that you're using
13:02Ani. The first setting is that you want
13:04to set your new cards to 50 new cards
13:06per day maximum. Why? Because you don't
13:08want to drown yourself in new Ani
13:10reviews. I can't tell you how many
13:11people do pre-made decks and they're
13:13trying to do 200 new cards a day cuz
13:14they're trying to get [music] through
13:15the entire deck and then they end up
13:17doing 5,000 cards or, you know, 2,000
13:19cards every day. Second, you want to set
13:21your max reviews to 9,999.
13:24And that allows you to make sure that
13:25you don't cap your reviews. Obviously,
13:26you're not going to do 9,999 cards per
13:29day. It just [music] means that if you
13:30have more cards that you need to review
13:32in a day, it's never going to stop you
13:34from doing those cards that are due on
13:36that particular day. The second thing
13:37that people struggle with when they're
13:39using ANI is how often they're using the
13:41different buttons. When you're reviewing
13:43cards, you're going to get the option of
13:44again, hard, good, or easy for how well
13:47you remembered that information on that
13:49card. A really good rule of thumb is
13:51that you only want to hit again or good.
13:53I would highly recommend that you don't
13:55hit hard and you should probably not hit
13:58easy much either. Again means I got it
14:00wrong and you're going to reset the
14:02interval. You should hit that about 10%
14:03of the time. Good means you got it right
14:05and you should hit that maybe about 90%
14:07of the time, especially if you're using
14:08something like FSRS to um do fewer cards
14:12per day, right? It really messes up the
14:14algorithm. The second thing that will
14:16happen is that um on on the opposite end
14:18of the spectrum, some people will be
14:20like a perfectionist and they're like,
14:21"Well, I didn't know one word and so I'm
14:24just going to hit hard or I might even
14:25hit again." Right? Don't do that.
14:27Learning how to use ANI is one of the
14:29hardest things that I've ever done. It
14:31was super frustrating and I made tons of
14:32mistakes, but it completely changed my
14:35score, my career trajectory, and my
14:37life. Retention is what lets your score
14:39compound. So now you're learning the
14:41right stuff and remembering it. But
14:42that's only half the battle. The other
14:44half is reading questions correctly.
14:46That starts with step number five. Step
14:49five is read the test writer's mind.
14:51Most people just read words. You need to
14:54read the intent of the person who's
14:56testing you. When we coach students, we
14:58see that up to 50% of missed questions
15:00have nothing to do with knowledge gap.
15:02You studied it, you knew it, but you
15:04still got it wrong. Why is that? The the
15:06most common reason why that is is that
15:07you didn't actually understand what it
15:09is that [music] the test writer was
15:10actually asking. This is where the CCSN
15:13framework comes in. The first C starts
15:15for context. Another way of [music]
15:17thinking about this is connection. You
15:18don't want to just read clues in
15:19isolation. One of the most common
15:21mistakes that we see people make is that
15:23they're scanning [music] for buzzwords
15:24and they'll see a buzz word and they're
15:25like, "Oh, anytime I see hematia, I
15:28think it's infective endocarditis." A
15:30broken clock is still right twice a day.
15:32The problem is is that sometimes that'll
15:34work, but often times that's just going
15:36to make you more confused as you read
15:38the question. Instead, you want to ask,
15:39"What single process could explain all
15:42of the clues that I've seen?" As you're
15:43going, you want to build a differential
15:45with each sentence. [music] For example,
15:46a headache alone is very non-specific.
15:48If you add visual changes, it's still
15:50pretty broad, but you've got a headache
15:52and visual changes and papadema. If I
15:55think, what are all of the things that
15:57could cause this? Now, it's a lot fewer.
16:00I might be thinking something with
16:02increased intraanial pressure and
16:04[music] all of the things that might
16:05lead to high ICP, but there's a lot
16:07fewer things when I take all of those
16:10different clues and try to put them
16:12together with a single explanation.
16:14Remember, every single sentence is there
16:16for a reason. Your job is to connect
16:18them and figure out why the test writer
16:20put it there in the first place. That's
16:21context, our first C. Our next C in the
16:24CCSN framework is chronology. Remember,
16:27test writers deliberately scramble the
16:28timeline. What you want to do is you
16:30want to always mentally resequence that
16:32into its chronological order. A
16:3322-year-old male presents with jaundice.
16:35He attended a music festival 3 weeks
16:37ago. He reports fatigue for the past 2
16:39weeks. Now, by itself, this might seem
16:41kind of confusing. Maybe you get it,
16:43maybe you don't. But I guarantee that if
16:45you reorder it chronologically, it'll
16:47make much more sense and your chances of
16:49getting it correct will skyrocket.
16:50Instead, we've got a guy who attended a
16:53music festival and then a week later,
16:54he's got fatigue that begins and then 2
16:57weeks after that, he has jaundice that
16:59appears. Now, hepatitis A becomes a lot
17:01more obvious. And the reason is is that
17:03the timeline reveals the diagnosis. So,
17:06that's chronology. The S in the CCSN
17:08framework stands for severity. Really,
17:10this is just asking how bad is it. This
17:12is critical for all exams, but
17:14especially for shelf exams, step two,
17:16and step three. The reason is is that
17:18severity usually is going to determine a
17:20lot of the management. So severity clues
17:22would be things like are they in the
17:24emergency department or is it just like
17:26a routine physical? If they're being
17:27brought to the emergency department,
17:29that's the most severe form of a disease
17:31usually [music] because it's so bad that
17:34they themselves are not physically
17:35capable of bringing themselves to the
17:37hospital. On the flip side, the opposite
17:39end of the spectrum would be something
17:40like a routine [music] physical. Right?
17:42If it's a routine physical, it means
17:43that it wasn't bad enough to be a
17:45symptom that was bad enough that it they
17:48they needed to schedule an appointment
17:50with [music] the doctor for that
17:51symptom. It's just something that you
17:53happen to pick up on your own as it just
17:55happened to be something that the
17:56clinician picked up on their own. Other
17:58signs of severity would be things like
17:59vitals, right? If you've got more
18:01hypotension or more tacocardia, that
18:03would be a sign of severity, right?
18:05Because those are things along the the
18:07[music] different sort of shock rating
18:08scales. Other things would be signs of
18:10end organ dysfunction. So, if you've
18:12altered mental status, if you're
18:14confused, if you've got uh low levels of
18:16consciousness, right, that would be a
18:17sign that you're having brain
18:18dysfunction, right? If you're not
18:19getting enough blood or oxygen to the
18:21brain, right, you can have [music]
18:22problems of consciousness. Other things
18:24would be like low urine output or
18:26elevated creatinine. Those would [music]
18:27be signs of kidney dysfunction, right?
18:29The disease is bad enough that now it's
18:31affecting your kidneys. The key thing to
18:33remember is that the more severe the
18:34presentation, the more aggressive the
18:36management. If a patient's coming in to
18:38their outpatient clinic and they're
18:40having mild symptoms and their vitals
18:41are completely normal, you're probably
18:43not going to rush them [music] to
18:44surgery. On the flip side, if it's
18:46really severe and they're being brought
18:47to the emergency department [music] and
18:49their vitals are still really horrible
18:51even after you've given them 2 L of IV
18:54saline, then sure, yeah, the management
18:57is probably going to be a lot more
18:58aggressive. Maybe you're going to do
18:59surgery. Maybe you're going to do
19:00something really emergent. Regardless of
19:02what it is, you know that it's going to
19:04be [music] probably faster and or more
19:06invasive. The N in CCSN stands for
19:08noise. I've spoken with people who write
19:10for the test and they say that as you
19:12get further and further along in the
19:14USML and shelf exams, you're going to
19:16see more noise. Noise is something
19:18that's irrelevant. Sometimes it's just
19:20sentences that are fillers. Other times
19:22they're actually trying to confuse you.
19:23If you've ever seen a myioardial
19:24inffection, right, like a heart attack
19:26question [music] for step one, there's
19:28typically not a lot of distractors or
19:30irrelevant information. For step two or
19:32shelf exams, the same condition, right,
19:34the same MI might have a patient who
19:37comes in with chest pain that is sort of
19:40this vague [music] epigastric pain and
19:43they also will have GIRD. So that
19:45there's also another possibility of
19:47maybe it's GIRD that's causing the chest
19:49pain. And in addition to that, they're
19:52not going to have an EKG yet. [music]
19:54And right like, but there's going to be
19:55something that's going to show you that
19:56it's an MI, right? So there's going to
19:58be things that might make you doubt
19:59whether it's an MI. And there's going to
20:00be things that are going to tell you
20:01that, oh, this is an MI, but just not
20:03make it very, very obvious. Remembering
20:05the N in the CCSN framework can help you
20:08to sort through what is signal, what's
20:10actually there to help lead you to the
20:11correct diagnosis, and what is noise or
20:13what's a distraction. For the students
20:15that are in our coaching program,
20:16remember that you can use the you smile
20:17GBT to analyze any question for CCSN and
20:20so that you can actually figure out what
20:22the intent is for every single sentence.
20:24Even if we don't work with you, you can
20:25still train yourself to do this manually
20:27on every single question that you
20:28review. So now once you've analyzed the
20:30vignette, you need to know [music]
20:31exactly what it is that they're asking
20:33before you look at the answers. That's
20:35step six. Step number six is to know
20:36your answer before you see the answer
20:38choices. Most students read the
20:39vignette, then immediately they look at
20:41the answer choices. The issue is that
20:43answer choices are designed to create
20:44confusion. They literally will look at
20:46how many people don't choose an answer
20:48choice and they'll say, "Well, no one
20:50chose that answer choice, so maybe we
20:51should switch for one where people are
20:53actually going to choose it." When you
20:54start by looking at the answer choices,
20:56you start playing a matching game
20:57instead of using your actual clinical
20:59reasoning. The solution is to make what
21:00we call a standalone question. A
21:02standalone question should make sense by
21:04[music] itself. Hence the term
21:05standalone. In other words, if someone
21:07asked you just the question, no
21:08vignette, no answer choices, you should
21:11still be able to answer it
21:12unambiguously. So, how do you do it?
21:14First, read the vignette using the CCSN
21:16framework that we talked about earlier.
21:18Second, cover up the answer choices or
21:20scroll up so that you can't see it.
21:22Third, ask yourself, what exactly are
21:24they testing me on? What's the
21:25diagnosis? What's the principle? Then,
21:28look for the choice that matches the
21:29answer that you're looking for. I'll
21:30give you an example. So I had a student
21:32who they they got a question wrong on a
21:35patient who had a massive PE. The
21:37question was something like what would
21:38you see on an echo cardiogram? Now
21:40granted this was a step one student and
21:43so that feels oddly specific and very
21:45difficult. So the wrong way to think
21:46about this question is to say well in a
21:4956-year-old patient who was a smoker and
21:51then took OCPS for 6 months and then
21:54comes in with you tacoc cardia and
21:56hypotension and you know sudden onset
21:58chest pain for the last 5 hours. What's
22:00the what would you see in an echo
22:01cardiogram? You could ask that. The
22:03problem is is that it's very very very
22:05unlikely that you'll actually have the
22:07specific knowledge to answer it.
22:08Instead, you want to think of a
22:10conceptual standalone question. What if
22:11you said instead, hey, there's a massive
22:14increase in right heart afterload. What
22:16would happen to the heart? Right? In
22:18other words, the fact that they're
22:19asking about an echo cardiogram, not
22:21that relevant. The fact that it's a PE
22:23is relevant, but only in that it's
22:25testing you on the concept of afterload.
22:27In other words, focus on the concept,
22:29not any of the specific details.
22:30Remember on step one, up to 70 or 80% of
22:34the test is what they call application
22:36of foundational science principles. What
22:37that means is that they're looking for
22:40you to apply concepts, not just memorize
22:43random details. So when you think, okay,
22:45so so once you have the standalone
22:46question, now think about the answer
22:48that you want to have. So if I were to
22:50basically squeeze off the pulmonary
22:52artery, what would happen to the right
22:53heart? Well, it would make sense if the
22:55right heart would get really dilated
22:57and, you know, wouldn't be able to pump
22:58very effectively because you're
23:00basically blocking off the flow of blood
23:02after it. So, I have that in my head and
23:04then I look at the answer choices and
23:05then [music] it makes a lot more sense
23:07that the answer was something like
23:08dilated right ventricle. Now, you've got
23:10your answer. But when you look at the
23:12choices, there's a specific way to
23:13evaluate them. That's step seven. Step
23:15seven is stop eliminating the right
23:17answer by ruling it in first. How many
23:20times have you gotten a question wrong
23:21and then realize that you actually
23:23crossed out the correct answer?
23:25Unfortunately, this happens more times
23:27than most people would like. The issue
23:29is is that our instinct is to start
23:30crossing things out first. In other
23:32words, we're like, uh, no, that doesn't
23:34really make sense. Nope, that can't be
23:35right. Or, oh, nope, that doesn't really
23:37make sense. That can't be right. When we
23:38focus on ruling out things first, we
23:40often eliminate the correct answers for
23:42the wrong reasons. So, why does this
23:43happen? We can always think of reasons
23:45why something isn't perfect. Students
23:47with anxiety or overthinking tendencies
23:49are especially vulnerable to this.
23:50Right? If you ever read an answer where
23:52you're like, I don't know, like 90% of
23:54this fits, 85% of this fits, but there's
23:56one thing that doesn't quite fit or I'm
23:58not really sure is the classic
24:00presentation. So, h this must not be
24:02right. So, I'm going to eliminate this.
24:03This can make up to 15 to 20% of your
24:06answers. I literally had one student who
24:08was studying for step two. She was like,
24:10I don't know. I'm I know the stuff
24:11really well, but I'm constantly getting
24:13things wrong on things that I've studied
24:15and I know quite well. So, I worked with
24:18her. She wouldn't be really stuck
24:19between two answer choices. She She
24:21would find one answer that mostly
24:22[music] made sense, but then she would
24:24say, "Well, there's this one thing that
24:25doesn't quite fit." No, that can't be
24:27it. And then she would just eliminate it
24:29and then choose [music] the other
24:30answer, whatever the other one was that
24:32was, you know, left standing. If you
24:33find yourself doing this, there is a
24:35solution. And I'm about to explain it.
24:36For each answer choice, you want to rule
24:38it in first before you rule it out. In
24:40other words, ruling it in means why
24:42would this be the correct answer. What
24:44scenario would this make sense for? Only
24:46after you've considered why it might
24:48make sense, then you can explain why it
24:50might not be correct. Don't ask why is
24:52this wrong. Instead, first ask why would
24:55this be right? Now, if you're doing all
24:57this and still struggling, the issue
24:58might be that you're trying to fix the
25:00wrong problem. That's step number eight.
25:02Step number eight is to fix the real
25:03reason that you're stuck. I can't tell
25:05you how many times people come to us and
25:06they say, "I know that there's a problem
25:08cuz my friends are studying half as much
25:11as I am and they're scoring twice as
25:13high, but I don't exactly know what the
25:15problem is." One of the reasons that our
25:16coaching exists in the first place is to
25:18be that outside perspective to look at
25:19what it is that you're doing to find out
25:21where exactly is the problem and what it
25:23is that you need to fix. That said,
25:25there are still tons of things that you
25:26can do on your own to try to diagnose
25:28exactly what the problem is. The issue
25:29is is that most people will say
25:30something like, "I'm bad at cardio."
25:32However, just saying, "I'm bad at
25:33cardio," doesn't give you anywhere to go
25:35or how it is that you need to actually
25:36[music] fix it or to become good at
25:38cardio. They'll also say things like, "I
25:39just need to do more questions," right?
25:41However, that's not a strategy. Most
25:42people, what they focus on is the
25:44symptoms, not the actual underlying
25:46cause. The fix is to break whatever
25:48thing that it is that you're struggling
25:49with into micro skills. So, instead of
25:51saying, "I'm bad at cardio," instead
25:53identify, "I can't distinguish between
25:54systolic and diastolic heart failure."
25:56That will give you something very
25:58specific. Now you can say okay well what
26:00exactly are the features of systolic
26:02heart failure? What exactly are the
26:03features of diastolic heart failure? And
26:05when you have that you can make a
26:06concept card like we were talking about
26:08earlier. Instead of saying I'm bad at
26:10questions figure out exactly which part.
26:12Is it a knowledge gap? Right? Is it just
26:13something that you didn't know? Is it an
26:15application error? Did you know it but
26:16you couldn't apply it? Was it a problem
26:18of CCSN? Right? Context, chronology,
26:20severity, and noise like we talked about
26:22earlier. Is it a problem of your
26:23standalone question? Did you just not
26:24identify exactly what the principle or
26:26the concept was and you were just stuck
26:28in all of the details? Were you stuck
26:29between two answer choices and you chose
26:31wrong because you happened to eliminate
26:33the answer that made most sense but
26:35wasn't perfect? Or was it an issue of
26:37timing? Like [music] did you proceverate
26:39on a certain number of questions where
26:41you were like, "Oh god, I can't move on
26:43from this question because I studied
26:44this and it's going to make me feel
26:46really bad if I get this wrong." Or is
26:47it an issue of timing where maybe you
26:49proceverated on a question where you
26:50were like, "Oh god, I'm so close. I'm so
26:53close. I'm so close. And you kept
26:54[music] pushing and waiting and hoping
26:56that maybe something clicked and then 6
26:58minutes later you've now wasted a bunch
27:01of time that you could have used on the
27:02questions at the end of the walk. If you
27:04want to be more systematic in figuring
27:05out exactly what the micro skills are
27:07that are holding you back, try the why
27:09technique. When you identify a symptom,
27:10ask why at least three times. For
27:12example, I'm not finishing blocks in
27:14time. Well, why? Well, I'm doing this
27:16because I'm getting stuck between two
27:17[music] answer choices. Okay. Well, why
27:18am I getting stuck between two answer
27:20choices? Well, I'm not exactly
27:21understanding what the question is
27:22really asking. The more specific you
27:24are, the easier it is for you to come up
27:26with a very specific solution. For
27:28example, in the case of Jay, who we
27:30talked about in the beginning, where he
27:31failed his test and then he went up to
27:3292%. When we analyzed Jay's errors, he
27:36wasn't weak in everything. He had some
27:37very specific problems. For example, he
27:39really struggled with chronology. So,
27:41anytime something was out of order, he
27:42just didn't automatically put it in the
27:44right chronological order. So even if he
27:46knew the answer, he still was getting it
27:48wrong because he wasn't letting his
27:50brain sort of identify it in the right
27:52way. Second is he really struggled with
27:53answer choice elimination, right? He
27:55would eliminate the correct answer often
27:57times because it wasn't perfect, right?
27:58His his expectation of what the correct
28:00answer was was different from the way
28:02that the test is actually written. And
28:04then finally, he had gaps in basic
28:05physiology because it happened during
28:07his first year. And so there was a lot
28:08of stuff that he just remembered. There
28:09was a lot of stuff that he had learned
28:11in his first year in physiology and had
28:13just forgotten. So what did we do? We
28:15built targeted exercise for each of
28:16them. That's exactly how we went from
28:18the bottom 3% to the top [music] 3%. He
28:20didn't just say, "Oh, I don't know. I
28:22guess I'm just not getting enough stuff
28:23done every day and I just need to push
28:25harder and just, you know, do more
28:28questions." He was very specific about
28:30what exactly were his biggest problems.
28:31[music]
28:32And then once he was very specific on
28:33them, it was a lot more obvious what the
28:35answer would be. Break one big problem
28:36into smaller problems that you can
28:38actually solve. Once you know what you
28:39need to fix, you need to practice under
28:41real conditions. That's step number
28:43nine. Step number nine is build test day
28:45stamina before it's too late. [music]
28:46Remember, timing is a skill and the
28:48longer that you wait, the harder it's
28:50going to be to build it. The mistake
28:51that so many students make is that they
28:53stay in untimed mode because it feels
28:55safer. They'll tell themselves something
28:57like, "I'll add timing once I feel
28:58ready." Then it's 4 weeks out and
29:00they've never practiced under pressure.
29:02My rule is is that untimed is fine for
29:04your first subtopic and maybe your
29:06second. [music] However, by day 10,
29:07everything should be timed. If you're
29:09still doing untimed blocks eight weeks
29:11out, you're setting yourself up for test
29:13day panic because the test is going to
29:14feel pretty different from the way that
29:16you've been practicing it. This matters
29:18because if you only ever practice
29:19untimed, you're training a skill that
29:21you won't necessarily be using on test
29:23day. Cuz remember, the clock is part of
29:25the real test. And finally, even if you
29:27know all of this, none of it matters if
29:28you don't actually do it. That's step
29:3010. Step 10 is get twice as much done in
29:32less time. Once you know that your
29:34studying is actually working, you need
29:36to create a system that's going to force
29:38you to get more done every single day.
29:40Because the more that you get done every
29:42day, the faster your score is going to
29:43go up and the less time is going to
29:44take. I know that sounds really simple.
29:46The problem is that you know what it is
29:48that you need to do, but so many times
29:51we're just not doing it. How often have
29:53you planned to study for 8 hours, but
29:54you actually study maybe two or three?
29:56We procrastinate, we feel guilty, and
29:58then we procrastinate more and more.
30:00Ultimately, if we want to get more done
30:01in less time and guarantee that we can
30:03pass step one, we need to understand why
30:06we procrastinate. Procrastination is
30:08ultimately just running away from
30:09something that's uncomfortable. We
30:10respond to psychological threats in the
30:12same way that we do to physical threats.
30:14If a lion is chasing after me, I'm going
30:16to run away from it. Similarly, if I've
30:18been getting really low UWorld scores
30:19and just thinking about UWorld makes me
30:22feel inadequate, then I'm also going to
30:24run away from UWorld. [music] Maybe not
30:26physically, but certainly emotionally. I
30:28was talking with a student recently who
30:30is technically studying full-time but
30:32you look at how much she's actually
30:33accomplishing every day and you're like
30:35whoa you're not actually spending a lot
30:36of time studying. What she told me is
30:38that because she's struggling with her
30:39approach results suck because her
30:41results suck. She's now feeling really
30:43awful every time she wants to sit down
30:45and study. And so instead of studying,
30:47she's cleaning her car. She's playing
30:49with her cats. She's cleaning the house.
30:52She's doing all of these things that are
30:53forms of what we call productive
30:55procrastination. The way to fix this is
30:57to start small. What we call the one
30:59push-up rule. If you tell yourself, "I'm
31:01going to do 40 questions." Not only if
31:03you've been getting low scores, is that
31:04going to feel overwhelming, but the 40
31:06questions itself is going to feel
31:07extremely daunting. As a consequence,
31:09you're going to want to procrastinate.
31:11Instead, if you tell yourself, "Okay,
31:12I'm just going to do one question." That
31:15feels a lot more doable. You're actually
31:16going to start to do it. Remember, the
31:18hardest part is starting. If I want to
31:19do a 100 push-ups, I shouldn't think I'm
31:21going to do 100 push-ups. Instead, I'll
31:23just tell myself, I'm going to do one
31:25push-up. And then often times, I will
31:27find that I will not stop at one push-up
31:29and I'll just keep going. The same thing
31:30is true with doing more questions, doing
31:32more Anki cards, doing more, you know,
31:34[music] pages of first aid, whatever it
31:36is that you want to accomplish. The next
31:37step is is that you want to track what
31:38you do. Remember, what you measure, you
31:40will actually do more of. So, if you
31:42track your Ani reviews, the number of
31:44new cards that you made, the number of
31:45questions that you completed, the time
31:46that you went to sleep, and the time
31:48that you woke up, I guarantee that you
31:49will do better in all of those things
31:51than if you didn't track them at all. In
31:52our coaching program, we actually have
31:54students create an accountability
31:55checklist where they actually document
31:57all of these things so that they can
31:59hold themselves accountable to getting
32:00more done in their day. The next thing
32:02can absolutely transform your studying
32:05and that's a time audit. The way that
32:06you do a time audit is that you track
32:08your time in 15-minute [music]
32:09increments for one day. Every 15
32:11minutes, just write down what it is that
32:12you did. It doesn't have to be really
32:13complicated. It could be something like
32:15I did an reviews or I [music] made lunch
32:17or I went and drove to the gym. Every
32:20single person who's done a time audit
32:21says that they got twice as much done,
32:23if not more, for less time studying. The
32:26final thing is external accountability.
32:28We have found that having a study buddy
32:29or someone that you are externally
32:31accountable for will help dramatically
32:33for you to get more done. For example,
32:34in our coaching program, we have a
32:36discord server where we've got study
32:38channels. In those study channels,
32:40people will actually share their screen
32:41while they're studying. It feels a
32:43little weird, honestly, and a little
32:45uncomfortable. But I also know that when
32:47I am sharing my screen, I am much less
32:49likely to watch Netflix and I'm a lot
32:52less likely to check my email because I
32:54know that someone is there. It's the
32:56exact same effect as when you're in the
32:57library and there's everyone else that's
32:59studying around you and everyone can see
33:00what's on your laptop. You are much more
33:02likely to actually sit down and get more
33:04work done. All right, so let's recap the
33:0510 steps to virtually guarantee that you
33:07pass step one. One, know in 24 hours if
33:09your approach is going to work. Use the
33:1180% mastery method. Two, master the
33:13whole page or the pages surrounding it,
33:15not just what it is that you missed.
33:17Three is to use the two card types that
33:19make forgetting impossible, concept
33:20cards and PC cards. [music] Four is
33:22never forget what it is that you learn
33:24using space repetition the right way.
33:25Five is learn how to read the test
33:26writer's intent. Master the CCSN
33:28framework. Six is know your answer
33:30before you look at the answer choices by
33:32coming up with the standalone question
33:34first. Seven is to stop eliminating the
33:36right answer by ruling in before you
33:37rule out. Eight is to fix the real
33:39reason that you're stuck. Breaking
33:40larger skills into micro skills, moving
33:42on to time blocks more quickly. And 10
33:45is to get twice as much done in less
33:47time by using accountability and
33:48starting small. The resources didn't
33:50change. His approach did. Now, let me
33:52answer some of the most common questions
33:54that I get about this approach. Question
33:55number one is, what if I'm already
33:56inicated and don't have time to start
33:58from scratch? The key thing to know
34:00about this is that you don't have to
34:01start from scratch. The other, I think,
34:03mistaken belief that I see a lot of
34:04people have is that they have to cover
34:06everything in order to be ready to take
34:08their test. Remember, I mean, if you
34:09just think about it mathematically, if
34:11I'm at 50% and I can get 80% on at least
34:14half of the material, I can get to 65%
34:17by just covering half of the material.
34:19And often times what you'll find is that
34:20if you can get half of the material to
34:2280%, you will naturally get more of the
34:25other questions correct because it's
34:27extremely rare that you're going to get
34:28one question that only involves one
34:30single organ system. [music] Right? Most
34:32of the problems deal with multiple organ
34:34systems. So even if I haven't covered
34:36endocrinology, if I've learned cardio
34:38really well, if I've learned GI very
34:39well, if I've learned pulmonary really
34:41well, there's a reasonable chance that
34:42there's a lot of overlap between those
34:44things and the systems that I haven't
34:45covered yet. By studying a certain
34:47number of things really well and making
34:48sure that they don't forget it, I will
34:49necessarily improve my score in other
34:52things. Also, in the worst case scenario
34:53that you're not ready to take your test,
34:55but your score is like pretty close.
34:57It's pretty obvious to know what it is
34:58that you should do next. [music] I think
34:59that the problem that I see a lot of
35:01people have is that they will do a full
35:04pass of UWorld and first aid at a very
35:07superficial level and then they'll
35:09improve their score maybe a little bit,
35:10but it's nowhere near what what it is
35:12that they need to get in order to feel
35:14comfortable to pass their test. The
35:15issue is that if I've already done a
35:16full pass and done everything that I
35:18thought that I needed to do and I'm
35:19still not there, it's not obvious what
35:21the next step is. But let's say that I
35:23only covered half of the material and I
35:24did 80% on all of the stuff that I
35:27covered and I'm still not there. So
35:29guess what? So if I'm pretty close to
35:30passing and I've only covered half the
35:32material, then it's pretty obvious that
35:34all I need to do to increase my chances
35:36of passing is just to do more of the
35:38material, right? Just do the the other
35:40half or do maybe 25% more. You don't
35:42have to do everything all at once. You
35:44don't have to do a complete pass. It's
35:46okay if you don't start from scratch.
35:48The key thing is is that you want to
35:50make sure that when you're studying,
35:51it's actually going to work. Cuz the
35:52worst thing that can happen if you've
35:54got a limited amount of time or
35:55especially if in your dedicated time is
35:57for you to wait 4 weeks until your next
36:00NVME and not know if your studying is
36:02actually working. Right? Remember, try
36:04and figure out immediately within a day
36:05or two [music] if your studying is
36:07actually going to move your score or
36:08not. Question number two is, what QBank
36:10should I use? Is you old enough? So to
36:11be honest, I don't think any of the
36:13Qbanks do a perfect job of mimicking
36:15what is done on the NBME. So you should
36:17still use NBMES as a way of tracking
36:21your progress and of trying to calibrate
36:24the way that you're reading questions to
36:25be more similar to the real exam. That
36:27said, I actually think that UWorld is
36:29the best QBank still for how it is that
36:32they phrase [music] the questions,
36:33right? It's not perfect. They probably
36:35add a little bit more noise than is
36:36necessary for step one. But I think
36:38overall it's probably the better of the
36:40Qbanks. I think that Ambos has a much
36:42better knowledge bank and I think if I
36:44wanted to learn something, I think Ambos
36:46might be a little bit better. However, I
36:48I personally find that Ambos questions
36:50tend to delve a little bit too much into
36:53the realm of kind of minutia and
36:55memorizing kind of small facts as
36:57opposed to the application of concepts
36:58which I think you will does a little bit
37:00better job of. Question number three is
37:02how many questions should I do per day?
37:03I think that this is a very misleading
37:05question to be honest. I think that
37:07quality should happen first and quantity
37:09should happen second. So what do I mean?
37:12If you aren't scoring at least 80% on
37:14the things that you're learning, then
37:16doing 100 questions a day might help a
37:18little bit, right? Cuz familiarity does
37:20help. There will be some questions that
37:22repeat and so you can see at least an
37:24initial jump in in your score. The issue
37:26is is that it tends to be relatively
37:28short-lived and people tend to plateau
37:30in my experience at a pretty low level
37:32if they're just cramming question.
37:33Instead, what I recommend [music] is
37:35again try to get to that 80% threshold
37:37or if you want to get a even higher
37:39score, right? Try to get it to a 90%
37:40threshold. Make sure that you know
37:42exactly what it takes to get to the
37:44level of where it is that you ultimately
37:45want to end up. Once you have that
37:47nailed down, then you start doing more
37:49questions. Eventually, it would be great
37:51if you could do 80 questions a day or 90
37:53questions a day or 100 or 120 questions
37:55a day, right? However, don't put the
37:58cart before the horse. Now, everything I
38:00just covered, it means nothing if you're
38:01using UWorld wrong. In my UWorld
38:03complete guide, I break down the exact
38:04settings, the five levels of mastery,
38:06and the study metrics that [music] make
38:08passing inevitable. Even if you're
38:09starting below passing right now, be
38:11sure to check it out

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