How I went from the bottom to the top 1 percentile on board exams

Most doctors are very bright people. I believe that what often sets apart those who perform well on the job and on exams isn’t raw intelligence but rather the ability to learn effectively.

In the MCAT and USMLE steps 1, 2, and 3, I did poorly and barely passed. In 2009, I took my family medicine in-training exam and fell below the minimum passing score. After taking almost five years away from residency for healing and to run an orphanage in Africa, I returned to residency and quickly improved my performance to the level that I recently scored in the top 1 percent in the country on my in-training exam. My score isn’t the only thing that has seen a boost. I’ve won an outstanding resident award and very well clinically. As you know, it’s hard to sound humble writing about how you went from grass to grace, so please bear with me. A few of my colleagues have asked me to tell them what I’ve done to improve so quickly.

The points I give below are my attempt to share what has worked for me in hopes of helping others move from good to great in their learning and patient care.

1. Don’t give yourself a worldview that frees you from the responsibility to do well on standardized exams. A lot of people who don’t have good scores on exams usually say, “I just don’t do well on standardized exams.” That statement right there condemns them forever to mediocrity on those exams. Others say, “exams don’t reflect my knowledge, I’d rather focus on caring for my patients and practicing good medicine.” When you do that, you give yourself a worldview that makes you a hero no matter what. We all know that standardized exams aren’t the best way in the world to measure knowledge. However, doing well on them is far from being a waste of time or something that happens by accident to those who are simply good test takers. If you prepare well, they can actually help you learn and become a better doctor.

Note: Watch your mindset. What you believe determines how you act and the way you live. If you don’t change the paradigm with which you view these exams, you would never improve on them.

2. Find out why you don’t do well on standardized tests and address it. For me, I simply read too slowly. Over the last two years, I’ve taken speed reading courses that have tremendously helped me improve my reading speed. And that has had a huge impact on my exam scores and my medical knowledge in general. I think this requires having a growth mindset that essentially says, “I can do everything that I need to do to succeed.”

3. Develop a passion for learning. This is a skill that anyone can learn. Genuinely enjoy learning and love to learn for fun.

4. Learn how to learn. It’s very easy for someone who is going to medical school or who has graduated and is practicing to forget that they can improve their learning skills. For me, this is an area that I’ve fallen in love with and have taken several courses on how to learn. I’ve enjoyed using learning techniques like memory palaces, creating and using mnemonics, chunking, simple recall, spaced repetition, and testing myself.

5. Remember that understanding is different from remembering. We all know that, but remembering it is important. To be successful learners, we need both a strategy for understanding new information and a strategy for remembering and quickly recalling it when needed.

6. Become an active learner. Ask lots of questions. Try to understand now and not procrastinate to understand later. It’s better to cover 1 oz of material with full understanding now than a pound you hope to fully understand later.

7. Balance performance with preparation. A lot of residents get caught up in the performance zone where they focus on solely getting the work done that they shut out their curious voices from actively asking questions and seeking to understand as they go through their work day. They just want to get the work finished. If you have to understand everything as you go, you may be slower initially, but as your understanding grows, you will gain both speed and confidence.

8. Keep records. Find a way to record important information you learn so that you can refer to it quickly when you need to see a patient. I recommend using a method that you can update quickly. I use a blog for this purpose, but one drive or google drive can work as well. In this day and age, a notebook may not be the best thing because it will get full and you can’t carry it with you all the time. Keeping records also helps with recall and memory.

9. Rest, sleep, and exercise. Stress, poor mental health, lack of sleep, and lack of exercise make memory consolidation and learning difficult. Find time in your busy schedule to sleep, rest, and get emotional first aid.

10. Study practice questions. Use previous exam questions as a guide for studying year-round not simply for preparing for exams. They expose you to many conditions that may not be seen in your current practice setting but which your examiners think are important for doctors in your specialty to know.

11. Take a full-length practice exam. I’ve found that taking a full-length examination several weeks before the real exam helps you with endurance and pacing. If you struggle to finish on exams, try that.

Kenneth Acha is a family medicine resident who blogs at

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