Want to crush USMLE Step 1? Here are some evidence-based study tips.

Interleveling strategy

  • Interleveling is the process of studying/learning multiple unrelated concepts across different subjects during the same study session.
  • This can make studying appear difficult and more disjointed. However, research shows it yields better exam results. This is attributed to better simulation of the exam environment as questions are presented in random order, and concepts are scattered throughout the test.
  • A literature review rated interleveling as having moderate utility, noting that there is not much literature on the subject, but the utilization of this technique yielded dramatic results on learning and retention of mathematical skills based on one study in the review.
  • Apply this technique to Step 1 studying by randomizing questions in UWorld or Kaplan Qbank to cover a variety of concepts in the same study session as opposed to studying practice questions based on subject or organ system.

Elaborative interrogation

  • Elaborative interrogation is the process of asking and understanding the “why” behind a given fact.
  • Students who used an elaborative interrogation technique had higher exam scores compared to students who just read the material.
  • The review concluded that elaborative interrogation had a clear beneficial effect on associative memory over short term periods. However, more evidence is needed to confirm the positive effects for long term memory. This research study rated elaborative interrogation as having “moderate utility.”
  • Apply this technique to Step 1 by understanding the mechanism of action or pathophysiology behind diseases, medications, etc., and avoid brute memorization.


  • Summarization is the process of synthesizing and truncating large amounts of information to focus on key points while excluding perceived unimportant information.
  • This received a low-utility rating due to the need for training and practice to develop effective summarizing skills. Their literature review found that summarization may have some utility among students who have some prior experience with summarization.
  • First Aid is already a summarization of Step 1 material, so do not waste time re-summarizing material in First Aid or making your own study guides for Step 1.

Highlighting and underlining

  • A study rated both as having low utility. Multiple studies have shown no differences in exam scores for students who highlighted or underlined compared to those who did not.
  • I am guilty of highlighting and underlining. I admit it seems to slow down my reading pace, but I feel that it keeps me focused. When I am not highlighting or underlining my mind tends to wonder out of boredom, and I often have to reread the material anyways.
  • Incorporate this into Step 1 studying by avoiding highlighting / underlining altogether, or by doing the highlighting/underlining prior to your dedicated study period.

Keyword mnemonics

  • Definition: Using mental imagery to associate words and concepts.
  • Keyword mnemonics had a low utility. However, the majority of studies evaluated had the student create the mnemonic. The low-utility rating was given due to concerns over the time-consuming process of creating mnemonics and the concern for retaining mnemonics over long periods of time.
    • The study did acknowledge the power of mnemonics stating “the overwhelming evidence that the keyword mnemonic can boost memory for many kinds of material and learners has made it a very popular technique.”
    • The study also showed that students who used mnemonics outperformed students who did not use mnemonics when tested immediately after the designated study period. This highlights a clear benefit for retaining knowledge in short term memory with the use of mnemonics. (Useful for, say, the USMLE board exam.)
  • One small study of fourth-year medical students at Icahn School of Medicine at Mount Sinai compared one group who used mnemonics to learn the porphyrin biochemical pathway vs. a control group. The mnemonic group scored 20 percent higher when tested three weeks later suggesting better long-term memory retention for the mnemonic group.
  • Mnemonics are routinely used in the hospital setting for many pre-operative protocols and patient handoffs (I-PASS and SBAR), which have shown to decrease medical errors.
  • Incorporate keyword mnemonics in Step 1 studying by looking over mnemonics periodically and most importantly in the week before the exam! Some resources that incorporate mnemonics include sketchy medical, picmonic, and med gunner.


  • Rereading is the most common study strategy used by students.
  • Rereading is of low utility based on mixed study results that failed to consistently demonstrate higher test scores for students that implemented rereading.
    • The authors stated that there was not enough evidence to draw conclusions on “spaced rereading” (rereading material over a long period of time).
    • There was evidence to show that the best gains for rereading occurred on the second reading. (Subsequent readings had diminishing returns.)
  • Apply this technique to Step 1 studying by aiming to reread the main source a total of three or four times through. (Again the benefits are unknown for rereading over time). Also, reread the main source two times close to the time of the exam (within two weeks of the exam).

Practice testing

  • Practice testing had high utility.
  • A good practice test creates a simulation of the testing environment and presents study material in a new light, thus, strengthening neural connections. Students who implemented this study method performed better on simple recall, cognitive reasoning, and had higher exam scores. (see chart below).
  • This is a MUST for implementing in your study routine for USMLE Step 1, plain and simple.

Distributed practice

  • Distributed practice had high utility.
    Definition: The practice of studying concepts over time as opposed to “cramming” the information.
  • Studying that was done over longer periods (six months vs. eight weeks) of time were shown to improve conceptual understanding and exam scores.
  • Implement this into Step 1 studying by starting early and avoid cramming! The study evaluated in this literature review showed benefits of studying six months prior to examination compared to the same material being covered in eight weeks.


  • There is not much evidence-based research available evaluating flashcard use and memory retention or testing performance.
  • Incorporate flashcard use into Step 1 studying, which can also incorporate interleveling and rereading/repetition strategies. Also, start studying early to incorporate the distributed practice technique.
  • Check out this flashcard app which has student made Step 1 flashcards for different subjects.

David Griffin is a pediatrician.

Image credit: Shutterstock.com

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