The Study Tools Students Should Actually Be Using

Every medical student feels the pressure to perform, despite the paradigm shift to pass/fail systems. Medical schools inevitably rank students, if not by hard metrics like test scores then by soft skills that fall under the professionalism umbrella. Residency programs, in turn, pack these metrics into their decision to rank applicants as prospective trainees.

The primary hurdle for students begins at step 1; that is to say, it begins with the US Medical Licensing Exam (USMLE) Step 1. No amount of preparation ever seems to be enough for the single most important test a budding doctor will take. Yet surviving Step1 merely initiates a series of exams that stand between you and your medical degree. Furthermore, transitioning to the clerkship years challenges students to test their bank of knowledge in real time. Responsibilities now include rounding with the care team, researching histories, and developing care plans for patients. All the while, students must prepare for shelf exams with the intent to sit for Step 2 at the end of the third year.

Medical students have an appetite for success and require reliable, effective materials to study. As such, test prep companies have responded to this demand by flooding the market with dozens of books, review courses, flash card sets, and question banks. The number of options quickly mushrooms to the point of paralysis.[1] Sadly, a paucity of independent analysis is available for the vast amount of resources. From the few studies available, an interesting trend appears to shed light on the best approach to succeed on standardized medical exams.

Red Book, Blue Book, Old Book, New Book

The harsh reality is that medical students face an overwhelming flood of information in 4 years of school. Having a comprehensive guidebook with which to synthesize the clutter of facts into a coherent message remains paramount. In fact, virtually everyone pursuing an MD must first master the FA
(First Aid). This bible becomes every medical trainee's go-to source for a thorough overview of the lessons found in the classroom, the lab, and the hospital.


In fact, a wise upperclassman once claimed that memorization of First Aid was practically required to excel on USMLE tests. One caveat: This student earned one of the highest Step 1 scores ever at his home institution. But as I'll detail later, other factors may have contributed to his success.

Diving deeper into a particular subject for shelf exams requires a more specialized book series. Publishers—including the Board Review Series, Case Files, Kaplan, Deja Review, and countless others—offer in-depth compositions on family medicine to surgery and everything in between. Yet anxiety inevitably sets in when students mull over picking the "best" from the rest: Informal student polls and blogs fail to identify the superior resource for each subject, let alone the dominant series for all core rotations.[2,3,4]

Fortunately, a forest can be seen through the trees: All reports suggest choosing one or two books on each subject (even combining those from different publishers) and sticking with them during each rotation. This way, students gain a sense of consistency that will increase the odds of retaining information for the tests. However, reading is only half the battle.

How do you know everything stuck?

21,000 Questions

Once you have sat through lecture after lecture and read a few dozen review books, the time to test yourself has arrived. True to form, the overwhelming majority of American medical students subscribe to a question bank; the USMLE World (UWorld) platform is the most prominent.

Some would argue success in medical school necessitates a subscription to the ubiquitous service. Fully 90% of medical students report using UWorld for at least one USMLE.[AMBOSS(formerly MIAMED) curates the work of dozens of physicians into a single interface originally for students preparing for Deutschland's version of USMLE Step 2. Since launching in the United States, the system now provides users with an English-language library of every pertinent topic learned during the clerkship years. AMBOSS subdivides every granular subject (eg, pediatrics) into finer categories (eg, pediatric neonatology), which contain highly specific, testable topics (eg, neonatal jaundice). Each topic breaks down further into pathophysiology, diagnostics, treatments, prognosis, and so on, such that students need only click a waterfall of tabs to unlock a wealth of information.

Moreover, all facts in AMBOSS directly link to primary sources through databases such as PubMed. After sufficient review, students can complete exam questions under a similar format as UWorld with the added feature of learning cards that appear under each answer choice. The cards correspond to the system's library source on the relevant learning objective for real-time feedback and review.

Yearly plans ranging from $45 to $365 offer a more affordable option than its direct competitor does. How can users truly compare? Speed of uptake overseas certainly speaks to the platform's popularity: 96% of German medical students use AMBOSS as their primary study resource after only 5 years on the market.[9] To that end, an AMBOSS representative reports internal data showing that users achieved 10 points higher on the M1 Physikum Examination compared with nonusers.

However, despite testimonials from US medical students on the AMBOSS website boasting the product's superiority, no objective data have measured its impact on shelf exams or Step 2 scores. The jury is still out on AMBOSS's role in American medical education; however, if the German experience holds, early adopters may find themselves ahead of the pack.

What Does It All Mean?

So what's a precocious student to do to land the residency of her dreams? The data both confirm and challenge commonly held suspicions surrounding optimum test preparation. Question banks appear to improve performance; however, students shouldn't expect to place in the 99th percentile of USMLE scores if they sit well below the 50th within their own class.


As it turns out, my wise friend from earlier consistently scores higher than nearly anyone ever on block exams, preclinical shelfs, and Step 1. His experience fits well with the findings of investigators at WVU, the University of Central Florida, and others: Undergraduate medical education performance tends to independently predict standardized exam scores.[10,11] Interestingly (or alarmingly, depending on your take), the previously mentioned studies found no correlation between dedicated study duration and subsequent test scores. Students who slack on reading during the semester or a rotation risk sacrificing a crucial period to learn in real time from professors and attendings; in fact, students ought to focus on consolidating as much information as possible during the preclinical and clinical years so that dedicated study periods become review sessions as opposed to primary learning experiences.


The value in expensive resources like question banks lies in using them to flesh out what is already in your head, not to place the information in there. Truly, your medical education occurs daily. Take control from day 1, and your investment will pay dividends down the road in residency and beyond.

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