How to Study

This section is about the underlying structure of your studying. If there is anything you read, let it be this section as it is the section that helps you learn how to learn.

The following discussion about the intricacies of studying I feel often goes unspoken and is rarely, if ever, taught in schools. For the lucky few, we learn these things through trial and error as well as through our own research as was the case for me. For the vast majority, however, “studying” and “learning” are things our educators assume we already know how to do. Far from it.

We were never taught how to learn effectively, let alone study.

What’s up next…

For those of you who are pressed for time I provided the most USMLE relevant material in the first five sections. The last  few sections have the more general but equally as important if not more so material on “learning how to learn”.

The “learning how to learn” section contains some of the most fascinating material I’ve come across in my research into the learning process not only as medical students but as human beings.

I will go over the extremely important material that Tony Buzan presents (the mind maps guy) as well as some fascinating material by the well-known educational consultant David A. Sousa. This material, I feel, is an example of the direction our educational system is taking (or at least should be) towards more efficient teaching methods.

Know Your Resources

PERSON

Ask yourself whether you work better individually, or in a group? Will you need a study group or maybe just one study partner? There are several sites online where you can find people studying for the steps in your area and you can meet up with them if none of your usual study group buddies live near you.

PLACE

Ask yourself if you study better at home or at a library? If you need to get out of the house then make sure you find an appropriate library with the space you need. Double check their hours since some public libraries close absurdly early (4 or 5 pm).

THING

Make sure you get your books and resources before studying. The worst would be to order a book and have it shipped later than planned messing up your study schedule. As you’ll see later you want to avoid pushing back dates for whatever reason.

Create Structure

Now that you have all the books you need and now that you know how and where you’ll be studying it’s time to structure your studying. The goal here is to create the “Big Picture” of how your next few months will look like.

For Step 1, I started by deciding to structure my studying the way First Aid was structured: General subjects first then Organ systems. I decided to pair up related subjects so that my learning was more integrative (eg. I learned Cardiology and Respiratory together).

For those preparing to take Step 2, I will put my schedule and calendar up here after having taken the exam. Here’s how I structured my studying for Step 1 after juggling things around and getting the feel for what I wanted to study when:

Part One – Subjects (First Month)

1. Anatomy

2.Embryology

3.Biostatistics

4. Behavioral

5. Biochemistry

6. Immunology

7. Microbiology

8. General Pathology

9. Pharmacology

Part Two – Systems (Second Month)

1. Respiratory

2. Cardiovascular

3. Musculoskeletal

4. Dermatology

5. Heme/Onc

6. Gastrointestinal

7. Renal

8. Neurology

9. Endocrine

10. Reproductive/Genitourinary

I chose to split up my studying into these two parts because when I went through First Aid the first time I could really see the benefits of using both a subject-based learning method as well as the systems-based method. Ultimately for me studying both ways allowed me to integrate material the most.

Create a Schedule

At this point, I think its important to ask yourself how much time do I have? 2 months? 3? Some of you might have 6 months or more at your disposal. Keep in mind that studying longer doesn’t necessarily translate to a higher score.

Also you should run through each section that you listed above and ask yourself how much time you need for each section. I’d suggest starting off with 3-4 days if you are familiar with the subject and up to a week or more if you haven’t done the material for some time. Anatomy and Biochemistry for me needed considerable review since I had forgot most of it so I gave myself a week for each.

If you haven’t already done so at this point, I’d suggest getting some sort of calendar software. The benefit to having a calendar on your computer or online is that you can rearrange dates and plans as things come up.

You can’t really plan for life. It has a way of throwing the most random stuff at you whether you’re studying for the USMLE or not. Be prepared to adapt and readapt your schedule to these unforeseen situations.

Avoid Burn-Out

Take a half day break every week to forget about your studies. Hell, if you’re just fed up take a whole day off. Do a hobby. Get involved in something non-medically related unless that is your sole passion which is fine.

I had travel plans after the exam so I spent every Saturday for 6 weeks learning Hindi. I love learning languages and this helped me to feel like I still had a life. This is what I call pacing yourself. You want to avoid burn-out.

In addition to your half-day breaks every week, you should also take 10 minute breaks during your studies. Break longer than 10 minutes and you’re much more likely to lose your momentum. I speak from experience. See the discussion in Learning How to Learn that reviews Buzan’s method of optimizing how much you retain by timing your breaks appropriately.

One final piece of advice for scheduling: You are creating a schedule for a reason. If you don’t bother to follow it on a day by day basis, what’s the point? What ends up happening is that when you have one or two weeks left you realize how much more you could have studied and resign yourself to, “I just want to pass”. Fair warning.

Time is Gold. Use it well from the very beginning.

Here are my calendars I used to keep myself on track. Halfway through Biochemistry, I started to use my calendar to outline my days in more detail. This helped me stay on track hour by hour towards the end.

January

February

March

Cramming Works…

…only if you know the material already. Its been shown that cramming before a test days before actually improves test scores. Naturally our brains tend to remember recently viewed material more easily (recency effect). However, there is NO WAY you can cram for the USMLE Steps. The last minute cramming can only work if everything you are looking at is familiar.

Because of this, I scheduled a final week right before the exam where I went through all the subjects intensively in rapid succesion hitting high yield points only. I was surprised at how many connections I made that week! Also, my percentages on the 48 Q blocks in UW went up a lot that week giving that extra confidence boost.

Practice Makes Permanent

What are you studying for? An exam. Wouldn’t it make sense to practice by actually taking exams? This is the rationale behind Qbanks and assessment exams like the NBME.

The old saying, “Practice makes Perfect” is rarely correct. Think of all the people you know who are horrible drivers. How long have they been at it? 20, maybe 30 years? Are they getting any better? Probably not.

What practice does is make things permanent. Practice causes our brains to concretize a particular task, concept, image, or idea. More of the cortex is devoted to it. Its not that we get better at the task just that we are less likely to forget it.

For our purposes this is great, since more practice with the different ideas and concepts means we wont forget it. It becomes permanently etched into our brains.

Repetition in Not Overrated

More practice essentially equates to repetition. An example: Think of what happens in Left Heart Failure. Blood might back up into the the Lungs leading to Pulmonary Edema. In more severe cases it backs up to the Right Heart. Now think of what happens when glucocorticoids bind to their cytosolic receptors. Previously bound heat shock proteins are released into the cytosol and the hormone-receptor complex simultaneously up-regulates anti-inflammatory proteins while preventing translocation of pro-inflammatory proteins.

Which of the two scenarios were you able to recall with more ease? Which was clearer for you? Unless you fall asleep holding a Biochemistry textbook, the Heart example was more clear. Why? Because you were told those particular series of cardiac events over and over and over again during med school. The heat shock proteins – not so much.

Build Your Stamina!

The other main purpose of practice exams and also of doing Qbanks is to build stamina. You should be so used to sitting in a chair for several hours doing questions that demand your undivided attention and focus that by exam day you won’t consider the eight hours daunting in the slightest.

To help me build my stamina I spent the last two and half weeks doing full 48 question blocks on Usmle World sometimes two or three in a day. I would spend the remainder of the day reviewing my wrong answers and learning considerably from them.

I’d then distill the main points from my wrong answers and put them on post-it notes and fill my wall with them. I would then periodically look at my wall during breaks and such to constantly remind myself of those key points.

This process of repetition and review for me turned each wrong UWorld answer into a strength. I literally surrounded myself with medicine. Behold the madness of the walls (2 of 4 shown):

Let me take a moment now to heap praise on Usmle World. I feel these guys did a superb job in creating a program that prepares students for the Step 1 exam. UW will train you to start thinking on the level of tertiary and quaternary order questions so that you get the hang of thinking at that level. Also, UW will give you the experience of being faced with questions where you have absolutely no f*%#ing clue. This is great because you’ll (hopefully) learn to not let this phase you, to move on quickly, and not waste any time, coming back only if you can.

Here’s the UW rationale: You train yourself by doing questions that are harder than the real thing so that on exam day you are more than ready.

Take Rocky for example. Before his fights how did he train? He trained faster and harder than what the fight might demand of him so that during the actual fight itself he’d be more than prepared.

As for assessment exams. They are an even better way to build stamina for the exam and get a feel for the real thing.

I personally think its a good idea to take an assessment exam at the beginning of you studies to see where your are, followed by another one half-way through to see if you have improved. If you haven’t improved by the half-way mark take time to seriously reconsider your study methods. Finally, take one just before your exam to get an idea of where you stand and use the last few days hammering out the kinks.

Perseverance

Take courage in knowing that hundreds of students are out there just like you going through the same emotional and mental highs and lows. For the majority of us, we have 2-3 months in which to study for Step 1.

Just remember that in 2-3 months you’l be done. DONE!

When all is said and done will you have any regrets about not having given your all? Will you want to go back in time and do things differently? Now’s your chance to make sure that is not the case when you’ve finished.

A Word About Forums

Forums might be a place you can go to to seek solace in the similar stories of your collegues’ anguish, but I warn you, there’s a lot of negativity in those forums, a lot of talk that’ll get you down and cause unnecessary worry.

I suggest you use forums sparingly and not waste too much time on them. I know way too many people who told me they would spend hours on them, HOURS! Reading other students’ scores will not help you raise yours anymore. Just my two cents.

True, there is some great advice on the forums and there is something to be said about the solace we feel reading the experience of others, but when you realize your “10 minute break” turned into 5 hours and its 4 in the morning, something needs to change.

The Untold Story of Studying

Studying is not something you do, it becomes a way of life.

As many of you know from first hand experience, studying is NOT as simple sitting down and reading a book.

Sometimes you’re not really in the mood and so you go get coffee and play some music to settle you down (or pump you up in some cases). Then you turn on the light, crack open the book, and bust out the gazillion highlighters (you know who you are).

The first sentence stares at you…Hmm, I wonder if I should just respond to Jill’s email now or later? Nah, I’ll do it later. C’mon FOCUS! Sentence two…IV drug abuse can lead to Infective Endocarditis…speaking of, I should tell Dan to watch Requiem for a Dream he’d love that movie, he’s into that kinda stuff. You know, I should probably just email Jill and get it over with.

Before you know it, 3 hours have gone by and you’ve covered all of…3 pages. Damn.

These Oddities…Thought and Emotion

Realistically I’d say we have hundreds of non-medically related thoughts throughout the course of a day, thousands maybe.

Usually we don’t even notice this as being a problem until we sit down and try to focus on the words in front of us. The seasoned among us last 10 minutes at very best. The rest? A minute or two. Try and find out for yourself.

For me, the trick is to mentally tell myself I will sit here and study for such and such time. Any thoughts that pop up I will acknowledge and let pass by. I make sure not to get caught up by the many tempting ideas: Get a snack, take a break, call so-and-so, email xyz, talk to this person or that, and on and on.

For those of you who’ve every tried meditation, studying is very much a meditation – focusing on one thing while having to deal with thoughts and emotions as they come up and  hopefully disappear.

Its, not even just getting sidetracked with thoughts, there is most definitely an entire emotional aspect to studying. Sometimes, you find yourself depressed for no reason. Wondering why you’re still in school studying when half your friends are already making money and getting on with their lives.

Other times, you’re in the middle of considering why there’s no connection between sun exposure and acral lentiginous melanoma when for absolutely no reason you remember that one time several years ago when you did that thing that you’ve regretted having done since. Man, if you could only go back in time.

There is such a deep well of thoughts and emotions within that we have to process and release or ignore and suppress (your choice) as we study that its no wonder studying can be so difficult.

For those of you with a very real reason to be upset, depressed, defeated, etc. I offer this: You are not alone. As cheesy as that sounds, its true. There are hundreds of students out there wrestling with the USMLE while also facing unimaginable difficulties.

I’m not going to pretend to know how you can best deal with these situations. Each person has his or her own story that they’ve learned to deal with in their own way. However, there is something empowering about knowing that what’s happening is normal. Sometimes awareness itself is often all that is needed to refocus.

Even so, there are clearly healthy ways of dealing with our emotions and not so healthy ways. If you find yourself dealing with thoughts and emotions coming up during studying I suggest not burying them nor ignoring them as they will come back. Often with much more force.

I don’t need to have a Ph.D to suggest that you try to address these issues and not suppress them. If its not a “quick-fix” sort-of deal, often just completely accepting what you’re feeling can be an extremely powerful first step.

By accepting, I mean acknowledging that its O.K. to feel what your feeling. There’s nothing wrong with where you are right now. The Beatles had it right when they said, “Let it Be.”

As for myself, when the going gets tough and either my thoughts are a mile-a-minute or I slip into regret of the past/fear of the future, I take a 5-minute break and address the issue. I take a deep breath, talk to someone, meditate, pray, anything, but I don’t ignore it. Like I said, these things have a nasty habit of popping back up unless they are faced head-on and acknowledged.

The point I want to make here, is that studying for months on end really is like a journey with its ups and downs. The whole internal aspect of studying, I feel, is never talked about, and yet its such a huge part of the studying process.

The Ebb and Flow of Consciousness

The degree of consciousness changes throughout the day. In the morning it reaches its first peak. By the afternoon it drops to a low point, followed by a slow climb to another peak mid evening. Then it starts to fade till bed time. This is natural.

What do we do to that natural ebb and flow? We take coffee in the morning to “wake up” since we went to bed at 3am last night. Morning flies by, we have lunch followed by more coffee or maybe a redbull this time. Afternoon, gone. By evening you start to get sleepy and maybe now you try the amazing 5-hour energy! Bam! You’re at it till 3am. Then you crash only to repeat the process.

I think the Spaniard farmers have it right. They get up at 6am-ish, work hard all morning. Lunch is followed by the siesta (essentially adult nap time). Late afternoon and Evening is productive and they might go to bed by around 10pm. Granted, this might be a bit utopian for some, but its definitely healthier.

We Learn In Sleep

This point dovetails the previous on taking into consideration the body’s circadian rhythms. Making sure we get enough sleep is crucial. We actually process the information we just learned during our sleep.

I’ve read that if you review the previous day’s material after a good night’s sleep you will find that many of the difficult concepts from the day before are suddenly made more clear the morning after.

There are some studies that suggest reviewing the previous day’s material in the morning greatly increases the chance that the material is stored in long-term memory and stays there.

This technique will serve to remind you what you just learned and give yourself an opportunity to really find out whether you’ve understood the material or just reviewed it on a superficial level. How often do we move on to the next topic without really having developed a firm grasp on the material?

Here’s a clip I stumbled upon on CNN that touches on this issue:

Dreaming helps Memory

Learning How to Learn

I hear and I forget. I see and I remember. I do and I understand.

-Confucius

In this section I’ll cover some very interesting odds and ends about how to make your studying more efficient. I offer a few tricks that I feel are extremely helpful and follow up with highlights from David A. Sousa’s “How the Brain Learns” as well as Tony Buzan’s “Study Skills Handbook,” two books I have found invaluable. Without further ado…

Associative Memory is a Two-way street

Often when we study, we are presented with material that’s organized from general to specific. For example, First Aid might have a particular section on an organ system say Respiratory, then we are given different subsections such as respiratory anatomy, physiology, pathology. It gets increasingly specific with the type of disease (lung cancer) followed by its subtypes (squamous cell, adenocarcinoma…) and correlating symptoms.

The trick here, however, is that questions present us with the specifics and symptoms and its up to us to come up with the generals.

Therefore, what I suggest is to be proactive in your studying. When reviewing a particular disease/subject memorize the info both ways: from general to specific then from specific to general.

It may seem redundant, but actually take the effort to mentally go both ways with the information.

For example, if you are studying lung cancer, as in the example above, a common way of approaching the subject in terms of memorization would be to mentally “see” lung cancers as a subject within lung pathology, then mentally run through the major lung cancers.

When you list each particular cancer (to memorize), lets take squamous cell, you would then list its unique features and symptoms (linked to smoking, cavitation present, centrally located,  PTHrP activity)

After this, you usually move on to the next topic. Instead, make sure to go back the other way mentally. In this case, you might ask yourself, “How would a patient present with squamous cell?” They might come with symptoms related to hypercalcemia due to the PTHrP, coughing, hemoptysis, and a history of smoking.

Mentally make the connections and associations needed so that if you saw this presentation you would think squamous cell carcinoma. Make sense?

What this is literally doing is “wiring” in new pathways in our brains that are then able to draw associations to the relevant and required info regardless whether your presented with something general or something specific.

Tricking the Mind

This is a particular trick I use when time is tight. Essentially its this: I trick my mind and take a “break” by studying something completely different for 5-10 minutes. Its worked a few times and gives me the impression that I’m really taking a break.

Usually, I fill these 10 minutes with a Kaplan video of some unrelated topic. Give it a shot it might be helpful for you.

So Fresh and So Clean

Your study area is in more ways than one a reflection of your mind. If its a mess, disorganized with papers and books all over the place, chances are that your mind and your thoughts are in the same state. Its no wonder you can’t “get” certain things or can’t remember certain things you’ve seen over and over again.

Some key points to consider for your study area:

  1. Have lots of light (sit by a window)
  2. Get good ventilation (O2 for your brain)
  3. Organize your books and notes
  4. Minimize the clutter

Interactive Learning

I cannot underline enough the incredible importance of engaging with the material. More specifically, I want to talk about how to review the material and at what intervals.

First let me address what I mean by review. When I say “Review” the material, I do not mean “Reread”. A good review would be trying to recall the material on your own and only going back to the books to fill in any gaps.

Ideally, this is best done by teaching someone else, but if thats not available talk out loud and teach an imaginary class instead.

As for the timing of your reviews, I suggest doing a quick mental review at the end of every chapter or section. Ask yourself, “What did I just read here? What were the key points?” Limit this mental review to about a minute so it doesn’t get tedious to do so every chapter.

As for proper in depth reviews, I used the intervals that Tony Buzan set up in his Study Skills Handbook. Take a look at this forgetting curve by a german psychologist, one of the first to study this phenomenon:

Buzan suggests the 1st review at 10 minutes, the 2nd at 24 hours, the 3rd review at 1 week, and the 4th at 1 month. I can’t say I stuck by this the entire time but I tried my best to organize my reviews accordingly and I’m very happy with the result.

Buzan and Sousa

To wrap up I wanted to suggest reading or at least skimming two books that I found very interesting and extremely helpful. They are Tony Buzan’s Study Skills Handbook and David Sousa’s How the Brain Learns.

Buzan covers things such as how powerful the brain really is, obstacles to effective study, speed reading, and how to effectively use mnemonics and other memory techniques.

Sousa goes into much more depth and seems to be targeting educators as his audience. He presents some very important information such as how the brain processes information, strategies for block scheduling, the role of motivation, creating meaning in new learning, and the impact of circadian rhythms on learning among many others.

I’m sure there are many other books out there that address study skills, I’m just sharing what helped me.

My plan is to return periodically to this page and update it accordingly with more helpful information and tricks I learn along the way. I hope its been helpful for you thus far.

How You Will Destroy This Exam

I offer for your viewing pleasure a taste of things to come. In this video: Rocky Balboa = You, Ivan Drago = Step 1. You’ll get your ass kicked but you’ll come out on top in the end. All the best in your studies!

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6 responses to “How to Study

  1. siddharth

    awesome!!

  2. siddharth

    can u post some link …. where i can download free usmle notes from… because i really need to clear this exam please… also suggest some books that i can refer to ….thanks

  3. pukukapono999

    Your blog entry is such a breath of fresh air from the conventional wisdom passed along. Good job!

  4. Lili

    Really awesome, This page makes me more comfortable and helps me to see things more clearly. Thank you for this great post!!

  5. diana

    I don’t think the word “Thank you very much, from the bottom of my heart.” would even suffice my gratitude and how much I appreciate this page of thoughtful advices and learning tips of yours but I’d like to to say it anyways; thank you very much for sharing this with us, truly from the bottom of my humble heart, thank you.

  6. Lt

    “there is most definitely an entire emotional aspect to studying. Sometimes, you find yourself depressed for no reason. Wondering why you’re still in school studying when half your friends are already making money and getting on with their lives.

    Other times, you’re in the middle of considering why there’s no connection between sun exposure and acral lentiginous melanoma when for absolutely no reason you remember that one time several years ago when you did that thing that you’ve regretted having done since. Man, if you could only go back in time.

    There is such a deep well of thoughts and emotions within that we have to process and release or ignore and suppress (your choice) as we study that its no wonder studying can be so difficult.”

    I ABSOLUTELY 100% AGREE WITH THIS.
    Often, the hardest part of studying is realizing I’m in a totally different place then all my friends and they have no idea how to relate. And of course I just wanna be out there with them too. It’s a very lonely quest.

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