MS1-MS2 doesn't teach you bread and butter medicine in enough detail

[efle]

Anki works as an adjunct for people who are also learning the underlying reasons behind everything. If you were to only memorize anki cards, you would not do well. I also said that knowing the esoteric stuff is the difference between a 240 and 260, so I agree that just knowing the fundamentals isn't enough for 250+. My point was that most of the exam is not esoteric information

Medicine requires a lot of memorization plus understanding. You likely got in the 250s because you learned the concepts and then you used rote memorization to refresh your memory on the memorized facts you need to know to help answer the question. The fact that you need to use memorized factoids to answer something to answer the question =/= esoteric. Like knowing the names of K-sparing diuretics is memorization, but it's not esoteric. The reason Boards and Beyond is so good because Dr. Ryan goes into reasoning plus he covers factoids.

Fair point, understanding is necessary but not sufficient for the high score ranges, and unfortunately everyone is throwing their effort into the rote recall arms race because that's what differentiates the high end. The scoring is roughly 1 question = 1 point, so on a 280 item test, the 5-10% of most esoteric items can be what defines the gap from 240 to 260+. Not to mention the 65% confidence interval on our scores is a whopping 16 point range, so getting a slightly lucky versus slightly unlucky test form can swing someone in the low 240s between 250 to 235, and completely change your prospects for matching. All in all, a pretty brutal emphasis to place on those esoteric tidbits.

And by esoteric I don't mean knowing which common diuretics are K-sparing, that's the kind of thing that deserves to be taught, memorized, and tested. I'm talking about the really wild stuff I've seen on test forms and my actual exam, like knowing what specific CYP sub-family metabolizes a specific narcotic. There is zero reason why that kind of flashcard trivia should determine whether I can train in popular surgical specialties.

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[GoSpursGo]

I meant that it should be encouraged to question the way a system is set up as the OP does, even if we have nothing better as of this moment. All man-made systems are inherently imperfect and could stand to improve. The USMLE isn’t an exam that descended from the heavens. It was written by people belonging to an institution with an agenda that isn’t necessarily there to benefit patients requiring care. And propagating a “just shut up and get behind the system or you’re lazy” mentality is faulty. It’s a natural law to take the path of least resistance, but let’s be real here, med school is not that. I can’t accuse any med student I met of being lazy, even if they try to find corners to cut every now and then because it’s more efficient.

I completely disagree. If you have an idea for how to improve a system, by all means share it, but complaining for the point of complaining doesn't help anyone.

And we're not saying "shut up and get behind the system or you're lazy," the attendings are telling you that this information that you think is useless actually is relevant once you're out in the world and practicing. The medical students don't seem to want to hear that, but I also don't think you're qualified to decide what is and isn't relevant.

Imagine its the year 2000 and your route to your desired residency spot was the same (impress on the wards, do research, get good letters) except that during preclinical you could learn from clinician professors about what they felt an MS3 should know, instead of pounding through tens of thousands of flashcards. Does that really not sound like a better tailored way to educate us?

You're training to be a doctor, not an MS3. This esoteric information may not make you look good on the wards as an MS3 but is an important foundation to have for later in your career.

I'm talking about the really wild stuff I've seen on test forms and my actual exam, like knowing what specific CYP sub-family metabolizes a specific narcotic. There is zero reason why that kind of flashcard trivia should determine whether I can train in popular surgical specialties.

If you want to argue that step 1 score shouldn't be so heavily weighted in residency admissions then that's fine, that's just not what the OP was saying. But given that polypharmacy is actually a huge problem, knowing things like how drugs are metabolized does seem relevant.

 

[Lawpy]

Step 1 mania is annoying and pretty pathological but i don't know if making that exam pass/fail and revamping the curriculum would help improve things

 

[Goro]

I was shocked by the opposite, after my MS2 they had us take a CBSE and it put me in the 210s. I did nothing but rote memorize as much esoteric factoids as I could stuff into my head during dedicated and went up 40 points into the 250s. I didnt get any smarter or better at reasoning in those months, just committed table after table of things I've never used since then into my short term memory, and it moved me from bottom quartile to top decile.

I honestly felt blindsided because I had spent all my effort during preclinical on learning the principles, and scoffed at my friends who were banging away at flashcards 24/7, but they were right and I was wrong. This style of prep caught on like wildfire for a reason. The step is not a test of who can best apply univerally learned fundamentals or reason through novel information. Or at least, that may be true of what you need to pass the exam, but it sure as hell isnt what gets you a 250+.

I think that you fell into the pernicious mindset that expounded often in this forum. Too many people, especially the FA and Anki acolytes, are too busy memorizing but not learning.

The whole point of Boards was not to assess mastery. they're to assess a minimum level of competency. It was PDs who turned them into a screening tool. I can't be too hard on the PDs...they're the ones who have to look at tons of residency apps. I believe it was the wise @gyngyn who voiced the opinion that if apps could be limited, then Step I mania might go away.

 

[Alkaidius]

I completely disagree. If you have an idea for how to improve a system, by all means share it, but complaining for the point of complaining doesn't help anyone.

And we're not saying "shut up and get behind the system or you're lazy," the attendings are telling you that this information that you think is useless actually is relevant once you're out in the world and practicing. The medical students don't seem to want to hear that, but I also don't think you're qualified to decide what is and isn't relevant.

I wasn’t complaining or advocating for complaining. Nor did I say the information was worthless. Point of fact, I played devil’s advocate in its favor and offered my own alternative. I said questioning/scrutinizing any system at all times is important. It’s literally how science works. Ideas rarely pop out of thin air. They’re more often built on previous questions and failures.

I disagree with OP’s solution, but I’m not against the idea of offering one. If it’s garbage, explain why (as many here have) and let it die in an abyss. But you never know who might be reading this that could be inspired to change it in the future.

 

[ace_inhibitor111]

I was shocked by the opposite, after my MS2 they had us take a CBSE and it put me in the 210s. I did nothing but rote memorize as much esoteric factoids as I could stuff into my head during dedicated and went up 40 points into the 250s. I didnt get any smarter or better at reasoning in those months, just committed table after table of things I've never used since then into my short term memory, and it moved me from bottom quartile to top decile.

I honestly felt blindsided because I had spent all my effort during preclinical on learning the principles, and scoffed at my friends who were banging away at flashcards 24/7, but they were right and I was wrong. This style of prep caught on like wildfire for a reason. The step is not a test of who can best apply univerally learned fundamentals or reason through novel information. Or at least, that may be true of what you need to pass the exam, but it sure as hell isnt what gets you a 250+.

Bro Step 2 and clinical medicine requires a hell of a lot of memorization too. That’s just how medicine is, it never ends. There’s a reason schools that take Step 1 after clinical years tend to do better, and I doubt it’s cause they did 20k Zanki flashcards.

 

[efle]

Bro Step 2 and clinical medicine requires a hell of a lot of memorization too. That’s just how medicine is, it never ends. There’s a reason schools that take Step 1 after clinical years tend to do better, and I doubt it’s cause they did 20k Zanki flashcards.

I've yet to see any studies that back up the clinical year improving Step 1 performance, after controlling for the higher MCAT scores of the early adopting schools and all the additional practice questions done in Uworld for step2/shelves. I did look, but didn't find it.

Like I said I don't mind memorization being a part of medicine, as long as it's for a valid reason. I hit the wards on my Medicine rotation fresh out of scoring great on Step 1 and thought well, I should be in good shape as far as my knowledge base!

Embarrassingly wrong, of course. At least 50% of what would've been good to know I hadn't seen yet because it's in OnlineMedEd and Step 2, not in Boards&Beyond/Pathoma or Step 1. I would so, so, so much rather have substituted the highest yield parts of that material instead of all the useless First Aid tables that have never come up once.

Just as an example here are some useless tables/lists from flipping through First Aid for a couple minutes:

Proteins of DNA replication fork
Lac operon
EVERY SINGLE STEP OF COLLAGEN SYNTHESIS
Trinucleotide repeats per each disease
Chromosomal locations of each hereditary disorder
Which biochem steps utilize each specific B vitamin, and other vitamins
Rate determining enzymes of each part of metabolism and their regulators
Steps of all the cycles (krebs, urea, cori, etc)
Proteins and steps of electron transport chain, their poisons, etc
Derivatives and precursors of each amino acid/their synthesis pathways
Glycogen storage diseases, their enzymes, etc
Lysozomal storage diseases, their enzymes, etc
All Apo proteins and steps of lipid processing; whether each is present in chylomicron vs remnant vs VLDL vs IDL vs LDL vs HDL
Familial lipid disorders, their enzymes, etc

Those examples are all from the FIRST Chapter of the book. Just the first few dozen pages of the 800 page book.

Why the **** are we letting students spend all day slamming this into their brain with the Spacebar button while not teaching all that Step 2 content they'll actually need as soon as they hit the wards?

 

[efle]

You're training to be a doctor, not an MS3. This esoteric information may not make you look good on the wards as an MS3 but is an important foundation to have for later in your career.

If you want to argue that step 1 score shouldn't be so heavily weighted in residency admissions then that's fine, that's just not what the OP was saying. But given that polypharmacy is actually a huge problem, knowing things like how drugs are metabolized does seem relevant.

I suppose it's possible that topic areas which never come up at all during MS3 could be an important part of my daily life in training in ENT or ortho or neurosurg etc...but I doubt it. But in my experience? The residents and fellows in these fields, who all scored great on Step to match there, laugh about how useless it is.

Step 1 score weighting is why we don't teach the important bread and butter Step 2 material, or at least, why no MS1-MS2 in their right mind would stop slamming spacebar long enough to learn it.

If you know off the top of your head which specific CYP subtypes metabolize all the common drugs - e.g. if you know cold that part of Codeine metabolism is by CYP2D6, as opposed to 1A2 (acetaminophen) or 2E1 (ethanol) or 2C9 (warfarin) and so on - I'll eat my hat.

 

[Lawpy]

I've yet to see any studies that back up the clinical year improving Step 1 performance, after controlling for the higher MCAT scores of the early adopting schools and all the additional practice questions done in Uworld for step2/shelves. I did look, but didn't find it.

Like I said I don't mind memorization being a part of medicine, as long as it's for a valid reason. I hit the wards on my Medicine rotation fresh out of scoring great on Step 1 and thought well, I should be in good shape as far as my knowledge base!

Embarrassingly wrong, of course. At least 50% of what would've been good to know I hadn't seen yet because it's in OnlineMedEd and Step 2, not in Boards&Beyond/Pathoma or Step 1. I would so, so, so much rather have substituted the highest yield parts of that material instead of all the useless First Aid tables that have never come up once.

Just as an example here are some useless tables/lists from flipping through First Aid for a couple minutes:

Proteins of DNA replication fork
Lac operon
EVERY SINGLE STEP OF COLLAGEN SYNTHESIS
Trinucleotide repeats per each disease
Chromosomal locations of each hereditary disorder
Which biochem steps utilize each specific B vitamin, and other vitamins
Rate determining enzymes of each part of metabolism and their regulators
Steps of all the cycles (krebs, urea, cori, etc)
Proteins and steps of electron transport chain, their poisons, etc
Derivatives and precursors of each amino acid/their synthesis pathways
Glycogen storage diseases, their enzymes, etc
Lysozomal storage diseases, their enzymes, etc
All Apo proteins and steps of lipid processing; whether each is present in chylomicron vs remnant vs VLDL vs IDL vs LDL vs HDL
Familial lipid disorders, their enzymes, etc

Those examples are all from the FIRST Chapter of the book. Just the first few dozen pages of the 800 page book.

Why the **** are we letting students spend all day slamming this into their brain with the Spacebar button while not teaching all that Step 2 content they'll actually need as soon as they hit the wards?

But biochem is cool 😢😢

 

[efle]

But biochem is cool 😢😢

Sure, so is organic chemistry, but I want my preclinical years to teach me more of what I need to know in my clinical years, not what's cool to learn for the sake of learning.

 

[longhaul3]

I've yet to see any studies that back up the clinical year improving Step 1 performance, after controlling for the higher MCAT scores of the early adopting schools and all the additional practice questions done in Uworld for step2/shelves. I did look, but didn't find it.

Those examples are all from the FIRST Chapter of the book. Just the first few dozen pages of the 800 page book.

To the first bolded point: Isn't that what the above poster was saying? Taking Step 1 after having learned all of the Step 2 material (whether or not one has taken CK yet) makes it far easier to study. I think that's where the effect comes from, so I don't see why it would need to be controlled for.

To the second: Isn't the first chapter the one that's like 80 pages of biochemistry, where all of that nonsense is concentrated? That represents basically the entirety of the minutiae, whereas the rest of the organ sections are the real bread and butter of Step 1. The minutiae of the other sections, like pauci-immune vs. linear immunofluorescence, are IMO very reasonable things to ask a doctor in training to learn.

I suppose it's possible that topic areas which never come up at all during MS3 could be an important part of my daily life in training in ENT or ortho or neurosurg etc...but I doubt it. But in my experience? The residents and fellows in these fields, who all scored great on Step to match there, laugh about how useless it is.

If you know off the top of your head which specific CYP subtypes metabolize all the common drugs - e.g. if you know cold that part of Codeine metabolism is by CYP2D6, as opposed to 1A2 (acetaminophen) or 2E1 (ethanol) or 2C9 (warfarin) and so on - I'll eat my hat.

To the next: This is a good point, and it's valuable that you've already realized it. There are some specialties in which zebras are actually quite common because they are inexorable and inevitably present the same way. NF2 and TSC are, for example, quite familiar to anyone in neurosurgery, despite being extremely rare. Interestingly (and tragically, for students and residents), given the pathophysiology of some brain tumors, the Krebs cycle comes back into play as well.

To the last point: Knowing those specific CYP isoforms cold is not truly necessary to score 250+ on Step 1. As someone said earlier, most of the tricky questions as far as I remember try to get at core topics in obscure ways. Obviously there are some things that you just have to know, but I don't think this level of detail is really necessary to excel.

 

[efle]

To the first bolded point: Isn't that what the above poster was saying? Taking Step 1 after having learned all of the Step 2 material (whether or not one has taken CK yet) makes it far easier to study. I think that's where the effect comes from, so I don't see why it would need to be controlled for.

To the second: Isn't the first chapter the one that's like 80 pages of biochemistry, where all of that nonsense is concentrated? That represents basically the entirety of the minutiae, whereas the rest of the organ sections are the real bread and butter of Step 1. The minutiae of the other sections, like pauci-immune vs. linear immunofluorescence, are IMO very reasonable things to ask a doctor in training to learn.


To the next: This is a good point, and it's valuable that you've already realized it. There are some specialties in which zebras are actually quite common because they are inexorable and inevitably present the same way. NF2 and TSC are, for example, quite familiar to anyone in neurosurgery, despite being extremely rare. Interestingly (and tragically, for students and residents), given the pathophysiology of some brain tumors, the Krebs cycle comes back into play as well.

To the last point: Knowing those specific CYP isoforms cold is not truly necessary to score 250+ on Step 1. As someone said earlier, most of the tricky questions as far as I remember try to get at core topics in obscure ways. Obviously there are some things that you just have to know, but I don't think this level of detail is really necessary to excel.

It's because there is then a tradeoff of performance on whatever is coming first instead - e.g. I wouldn't find it appealing to have my school's students score a bunch lower on the medicine and surgery NBMEs. The idea was that seeing actual care would make it easier to recognize in vignettes or remember features about it better. If the goal was just to do more practice questions, schools could just teach to the boards and buy everyone Qmax and Kaplan.

Like I said earlier my position has never been that all the step material is useless. Lots of it is great. It's certain sections like biochem, immuno, genetics, micro, pharma, embryology, hormones, obscure path, very rare neuro, lots of the renal physio that tend to go way into the weeds and are the worst offenders for sure. That's the stuff that would put freshly boarded hospitalists in danger of failing if they had to take the Steps again next week.

I'm totally fine with asking a neurosurgeon what chromosomes the NF genes are located on during their boards then, if that's important to the board writers. I just don't see why that gets such emphasis for an MS2. As far as core topics in obscure ways, I was praying that would be the case, and went into dedicated expecting it to be. That's what I was always excellent at, I was top of class at my college and top 0.1% on the MCAT because reasoning was my shiz. Similar experience for one of my buddies who also eschewed flashcarding, who himself had a perfect MCAT score. We had a very rude awakening when we found out we were actually at the 215-220 range and had to spend the next months frantically memorizing all the useless things I described above to catapult us up into the 250s. A test that primarily asks you to apply universally learned fundamentals doesn't behave like that, and wouldn't have modern students worshipping a flashcard app. Maybe things have changed since you took it - I can tell you that the Practice NBME Form 18 has had a scaling swing of approximately 12 points in just the last 3-4 years (that is, a 248 today was a 260 in 2016). Maybe five or more years ago you really could just master the fundamentals, but that CYP example was directly off my test, and there were many other questions like it.

 

[sloop]

It's because there is then a tradeoff of performance on whatever is coming first instead - e.g. I wouldn't find it appealing to have my school's students score a bunch lower on the medicine and surgery NBMEs. The idea was that seeing actual care would make it easier to recognize in vignettes or remember features about it better. If the goal was just to do more practice questions, schools could just teach to the boards and buy everyone Qmax and Kaplan.

Like I said earlier my position has never been that all the step material is useless. Lots of it is great. It's certain sections like biochem, immuno, genetics, micro, pharma, embryology, hormones, obscure path, very rare neuro, lots of the renal physio that tend to go way into the weeds and are the worst offenders for sure. That's the stuff that would put freshly boarded hospitalists in danger of failing if they had to take the Steps again next week.

I'm totally fine with asking a neurosurgeon what chromosomes the NF genes are located on during their boards then, if that's important to the board writers. I just don't see why that gets such emphasis for an MS2. As far as core topics in obscure ways, I was praying that would be the case, and went into dedicated expecting it to be. That's what I was always excellent at, I was top of class at my college and top 0.1% on the MCAT because reasoning was my shiz. Similar experience for one of my buddies who also eschewed flashcarding, who himself had a perfect MCAT score. We had a very rude awakening when we found out we were actually at the 215-220 range and had to spend the next months frantically memorizing all the useless things I described above to catapult us up into the 250s. A test that primarily asks you to apply universally learned fundamentals doesn't behave like that, and wouldn't have modern students worshipping a flashcard app. Maybe things have changed since you took it - I can tell you that the Practice NBME Form 18 has had a scaling swing of approximately 12 points in just the last 3-4 years (that is, a 248 today was a 260 in 2016). Maybe five or more years ago you really could just master the fundamentals, but that CYP example was directly off my test, and there were many other questions like it.

I dont mean to be rude about this, but I think that this post confirms my hypothesis that many of the med students who complain about such things are mostly salty that med school is competitive and difficult.

I mean, your post smacks of a typical med student who never encountered much difficulty but is now feeling that the system is flawed and unfair because they have to work hard to separate from the pack.

 

[Lawpy]

I dont mean to be rude about this, but I think that this post confirms my hypothesis that many of the med students who complain about such things are mostly salty that med school is competitive and difficult.

I mean, your post smacks of a typical med student who never encountered much difficulty but is now feeling that the system is flawed and unfair because they have to work hard to separate from the pack.

I thought he's arguing against memorizing useless details that can't be reasoned through

 

[efle]

I dont mean to be rude about this, but I think that this post confirms my hypothesis that many of the med students who complain about such things are mostly salty that med school is competitive and difficult.

I mean, your post smacks of a typical med student who never encountered much difficulty but is now feeling that the system is flawed and unfair because they have to work hard to separate from the pack.

*shrug* I still did great on it, it was just a couple months of annoying memorization. My beef is with the effect I'm seeing on the system at large, like students flashcarding boards prep religiously from their very first semester. I escaped any consequences myself.

 

[Lawpy]

Although this thread makes me more hyped for more charts and figures. I like SDN data analyses

 

[Goro]

I've yet to see any studies that back up the clinical year improving Step 1 performance, after controlling for the higher MCAT scores of the early adopting schools and all the additional practice questions done in Uworld for step2/shelves. I did look, but didn't find it.

Like I said I don't mind memorization being a part of medicine, as long as it's for a valid reason. I hit the wards on my Medicine rotation fresh out of scoring great on Step 1 and thought well, I should be in good shape as far as my knowledge base!

Embarrassingly wrong, of course. At least 50% of what would've been good to know I hadn't seen yet because it's in OnlineMedEd and Step 2, not in Boards&Beyond/Pathoma or Step 1. I would so, so, so much rather have substituted the highest yield parts of that material instead of all the useless First Aid tables that have never come up once.

Just as an example here are some useless tables/lists from flipping through First Aid for a couple minutes:

Proteins of DNA replication fork
Lac operon
EVERY SINGLE STEP OF COLLAGEN SYNTHESIS
Trinucleotide repeats per each disease
Chromosomal locations of each hereditary disorder
Which biochem steps utilize each specific B vitamin, and other vitamins
Rate determining enzymes of each part of metabolism and their regulators
Steps of all the cycles (krebs, urea, cori, etc)
Proteins and steps of electron transport chain, their poisons, etc
Derivatives and precursors of each amino acid/their synthesis pathways
Glycogen storage diseases, their enzymes, etc
Lysozomal storage diseases, their enzymes, etc
All Apo proteins and steps of lipid processing; whether each is present in chylomicron vs remnant vs VLDL vs IDL vs LDL vs HDL
Familial lipid disorders, their enzymes, etc

Those examples are all from the FIRST Chapter of the book. Just the first few dozen pages of the 800 page book.

Why the **** are we letting students spend all day slamming this into their brain with the Spacebar button while not teaching all that Step 2 content they'll actually need as soon as they hit the wards?

Just out of curiosity, have you had any pharmacology yet?

If so, do you think it's important to know something about topisomerase inhibitors?

Or do you just want to be at the level of "it inhibits this enzyme, period"? Or "it inhibits this enzyme, and it kills cancer cells (or these bacteria)"?

Because if so, PA and NP school is over that way --->

It's not about merely memorizing, it's about learning. There's a why behind what you do as a doctor.

The one thing I'll agree on is that no one should have to learn about the Krebs cycle after college!

 

[libertyyne]

My personal experience has been that even in m3 my first two years of education provided me with a solid foundation of information to build on and understand what is going on around me, to where If i could not outright answer a clinical question on the wards I would know what to search for and where to look for the information.

There is without a doubt some questionable content in m1,m2, but i personally feel better off for having been exposed to it.

I think the people in my class who have struggled on the wards to generate decent differentials and plans, or interpret labs or sub-specialist notes and plans were the same people who did not do well on boards.

I am absolutely grateful that i did those 500K anki reviews or 8k questions , in addition to doing well on the boards i dont feel completely out of place or have a difficult time understanding what the more complicated things are going on around me in the hospital or with the patients I am covering.

 

[Alkaidius]

The one thing I'll agree on is that no one should have to learn about the Krebs cycle after college!

The ONE thing I’d agree on is keep the Lac Operon in the undergrad micro weed-out course where it belongs, personally lol.

 

[efle]

Just out of curiosity, have you had any pharmacology yet?

If so, do you think it's important to know something about topisomerase inhibitors?

Or do you just want to be at the level of "it inhibits this enzyme, period"? Or "it inhibits this enzyme, and it kills cancer cells (or these bacteria)"?

Because if so, PA and NP school is over that way --->

It's not about merely memorizing, it's about learning. There's a why behind what you do as a doctor.

The one thing I'll agree on is that no one should have to learn about the Krebs cycle after college!

Yeah I took pharma back as an M1, I'm on the tail end of most of my cores on M3 now. I guess it's tough to tease out exactly what is and isn't a waste of time sometimes.

As an example, is it good to know that GABA is generally inhibitory? Sure. Good to know that things like alcohol, benzos, barbituates all depress nervous activity by potentiating GABA? Sure.

Good to memorize whether it's by increased frequency of channel activation versus duration of channel activation per each type? Waste of time. Could absolutely never be clinically relevant.

But then for the Sketchy Pharma page on these, they include both, and the flashcard decks have flashcards for both.

That's an extremely specific example. But if you got yourself a brand new highlighter and started going through First Aid highlighting the extra factoids that could never affect your care of patients, you'd run out of ink way before you ran out of examples.

 

[efle]

My personal experience has been that even in m3 my first two years of education provided me with a solid foundation of information to build on and understand what is going on around me, to where If i could not outright answer a clinical question on the wards I would know what to search for and where to look for the information.

There is without a doubt some questionable content in m1,m2, but i personally feel better off for having been exposed to it.

I think the people in my class who have struggled on the wards to generate decent differentials and plans, or interpret labs or sub-specialist notes and plans were the same people who did not do well on boards.

I am absolutely grateful that i did those 500K anki reviews or 8k questions , in addition to doing well on the boards i dont feel completely out of place or have a difficult time understanding what the more complicated things are going on around me in the hospital or with the patients I am covering.

I think you credit too much to the method, though. Good students in MS1-MS2 deserve to feel reasonably prepped for the wards. But being a good, reasonable prepped student should not be synonymous with doing half a million flashcards and 3 QBanks. If you'd been born 20 years sooner you'd still have been more competent than a lot of your peers on the wards without any of that.

 

[bananafish94]

I’m very grateful for my robust basic sciences education and strongly believe that the preclinical curriculum is crucial. That said, I think this obsession with Step 1 is rotting medical education from the inside out.

 

[Govols22]

I’ll never forget the day I learned that Goodpasture Syndrome is 1 in a million. Like damn you probably have better odds of having bladder cancer and TB at the same time.

 

[Chemist0157]

I’ll never forget the day I learned that Goodpasture Syndrome is 1 in a million. Like damn you probably have better odds of having bladder cancer and TB at the same time.

If you do pulm or renal, you'll see it. I actually didn't realize the incidence was that low because I have seen it more than once.

 

[Chemist0157]

I won't dig my heels into the ground too much as I understand where y'all are coming from, and it seems like the Step 1 circus has gotten worse since even my few years ago, but know that if you don't learn basic sciences in early medical school, you'll probably not going to have another opportunity. Clinical knowledge takes over with more time and with the expectation that you already have the first years under your belt.

I think most of it is important and useful. We could quibble about what percent is useless. Thinking back, I can remember the occasional lecturer who spent an hour talking about a very obscure topic that could only muster 1 question on the test and never seen again, even on Step, and that would have my vote for a ridiculous waste of time.

 

[GoSpursGo]

I suppose it's possible that topic areas which never come up at all during MS3 could be an important part of my daily life in training in ENT or ortho or neurosurg etc...but I doubt it. But in my experience? The residents and fellows in these fields, who all scored great on Step to match there, laugh about how useless it is.

Step 1 score weighting is why we don't teach the important bread and butter Step 2 material, or at least, why no MS1-MS2 in their right mind would stop slamming spacebar long enough to learn it.

If you know off the top of your head which specific CYP subtypes metabolize all the common drugs - e.g. if you know cold that part of Codeine metabolism is by CYP2D6, as opposed to 1A2 (acetaminophen) or 2E1 (ethanol) or 2C9 (warfarin) and so on - I'll eat my hat.

To be fair, a decent amount of anatomy and other things you learn in first year that you likely care about, I've long since dumped into the deep recesses of my brain.

I think your second point is just wrong. The first two years have been about basic science forever, and the stress associated with the increasing importance of step 1 score is independent of that.

Obviously I don't know all of those off the top of my head, though I could tell you CYP3A4 metabolizes most chemo drugs. Again, the point isn't really the specific minutiae but the general concept. I think your underlying complaint still gets down to how important step 1 scoring is, which is valid, but has nothing to do with the value of what you're supposed to learn in MS1 and 2.

 

[Goro]

I won't dig my heels into the ground too much as I understand where y'all are coming from, and it seems like the Step 1 circus has gotten worse since even my few years ago, but know that if you don't learn basic sciences in early medical school, you'll probably not going to have another opportunity. Clinical knowledge takes over with more time and with the expectation that you already have the first years under your belt.

You correct in the bolded observations. There are SDners who now seem to think that medical education ends with Step I. Their self-worth is wrapped up in that exam.

 

[GoSpursGo]

You correct in the bolded observations. There are SDners who now seem to think that medical education ends with Step I. Their self-worth is wrapped up in that exam.

I will throw them a bone and admit that some of the competitive residencies have decided that is how they value applicants. It’s not like Med students all decided to start caring about an arbitrary number, it is an understandable source of stress.

Where I am trying to draw a distinction is that you can simultaneously believe that step 1 is a flawed measure to determine residency fate and also find value in the basic science curriculum for a practicing physician.

 

[Goro]

I will throw them a bone and admit that some of the competitive residencies have decided that is how they value applicants. It’s not like Med students all decided to start caring about an arbitrary number, it is an understandable source of stress.

Where I am trying to draw a distinction is that you can simultaneously believe that step 1 is a flawed measure to determine residency fate and also find value in the basic science curriculum for a practicing physician.

Oh, I fully agree! But my point was not that the Step score is what keeps one out of, say, Ortho or Derm, but the score itself is a measurement of self-worth and value as human beings to these students. It's actually separate from their career goals!

These are probably the same people who equated their SAT and MCAT scores with self-worth. Tiger parents (who come in all sizes, shapes and colors) can do a hell of a lot of damage to their kids.

 

[Matthew9Thirtyfive]

I've yet to see any studies that back up the clinical year improving Step 1 performance, after controlling for the higher MCAT scores of the early adopting schools and all the additional practice questions done in Uworld for step2/shelves. I did look, but didn't find it.

Like I said I don't mind memorization being a part of medicine, as long as it's for a valid reason. I hit the wards on my Medicine rotation fresh out of scoring great on Step 1 and thought well, I should be in good shape as far as my knowledge base!

Embarrassingly wrong, of course. At least 50% of what would've been good to know I hadn't seen yet because it's in OnlineMedEd and Step 2, not in Boards&Beyond/Pathoma or Step 1. I would so, so, so much rather have substituted the highest yield parts of that material instead of all the useless First Aid tables that have never come up once.

Just as an example here are some useless tables/lists from flipping through First Aid for a couple minutes:

Proteins of DNA replication fork
Lac operon
EVERY SINGLE STEP OF COLLAGEN SYNTHESIS
Trinucleotide repeats per each disease
Chromosomal locations of each hereditary disorder
Which biochem steps utilize each specific B vitamin, and other vitamins
Rate determining enzymes of each part of metabolism and their regulators
Steps of all the cycles (krebs, urea, cori, etc)
Proteins and steps of electron transport chain, their poisons, etc
Derivatives and precursors of each amino acid/their synthesis pathways
Glycogen storage diseases, their enzymes, etc
Lysozomal storage diseases, their enzymes, etc
All Apo proteins and steps of lipid processing; whether each is present in chylomicron vs remnant vs VLDL vs IDL vs LDL vs HDL
Familial lipid disorders, their enzymes, etc

Those examples are all from the FIRST Chapter of the book. Just the first few dozen pages of the 800 page book.

Why the **** are we letting students spend all day slamming this into their brain with the Spacebar button while not teaching all that Step 2 content they'll actually need as soon as they hit the wards?

It’s just one school, but our school’s scores went up when we switched to a condensed preclinical curriculum that’s systems based and taking step in M3 after a year of rotations.

 

[slowthai]

It’s just one school, but our school’s scores went up when we switched to a condensed preclinical curriculum that’s systems based and taking step in M3 after a year of rotations.

I was thinking about this today; how are you planning to study? Are you going to finish Zanki before you start rotations and then jump on a step 2 deck + UWorld for step 2 on top of keeping up with your Zanki reviews during your rotations?

 

[Matthew9Thirtyfive]

I was thinking about this today; how are you planning to study? Are you going to finish Zanki before you start rotations and then jump on a step 2 deck + UWorld for step 2 on top of keeping up with your Zanki reviews during your rotations?

No idea yet, but our 4th years sent out an email with the resources they used for each rotation. I'll probably just use those while keeping up with my Zanki reviews. But who knows. I'm just trying to survive cardio.

 

[MedicineZ0Z]

Solution identified: PA school.

What I said does not remotely resemble PA school. When I pimp an MS3 and they can't fully remember bread and butter stuff but can tell me about some enzyme deficiency disease and put it on their differential, that's an issue. Can easily be addressed by going MORE in-depth on bread and butter topics.

Also, Step 2 >>>>> Step 1.


You guys going on and on about how this step 1 knowledge separates us from PAs/NPs are delusional. Nurses and midlevels in this era constantly judge the lack of clinical acumen of many residents. It's part of the reason we get less respect than 20 years ago. You can recite the mechanism of ultra rare diseases. Cool. And maybe over the span of 10 years you'll make that one rare diagnosis. But... you look like a deer in the headlights as a resident when a nurse asks you what you want to do for a patient who isn't looking so good.

 

[ace_inhibitor111]

What I said does not remotely resemble PA school. When I pimp an MS3 and they can't fully remember bread and butter stuff but can tell me about some enzyme deficiency disease and put it on their differential, that's an issue. Can easily be addressed by going MORE in-depth on bread and butter topics.

Also, Step 2 >>>>> Step 1.


You guys going on and on about how this step 1 knowledge separates us from PAs/NPs are delusional. Nurses and midlevels in this era constantly judge the lack of clinical acumen of many residents. It's part of the reason we get less respect than 20 years ago. You can recite the mechanism of ultra rare diseases. Cool. And maybe over the span of 10 years you'll make that one rare diagnosis. But... you look like a deer in the headlights as a resident when a nurse asks you what you want to do for a patient who isn't looking so good.

What you’re saying doesn’t make sense. So residents lack clinical acumen yet they are the ones who’ve taken Step 2 and also have 2+ full years of clinical experience. How does that have anything to do with Step 1 or what nurses think of them lol.

 

[VA Hopeful Dr]

What you’re saying doesn’t make sense. So residents lack clinical acumen yet they are the ones who’ve taken Step 2 and also have 2+ full years of clinical experience. How does that have anything to do with Step 1 or what nurses think of them lol.

Of course residents lack clinical acumen, that's why they're in residency in the first place.

 

[Med Ed]

What I said does not remotely resemble PA school. When I pimp an MS3 and they can't fully remember bread and butter stuff but can tell me about some enzyme deficiency disease and put it on their differential, that's an issue. Can easily be addressed by going MORE in-depth on bread and butter topics.

UME has to content with a massive explosion of medical information. It also has to provide a common foundational level of education for students who go into everything from general pediatrics to neurosurgery of the left angular gyrus. If something is truly "bread and butter" then it will, by definition, become routine as part of residency training.

Funny thing about rare diseases: while they are individually rare, lump them all together and you end up with something fairly common. All practitioners see rare diseases on a regular basis. They just can't predict which ones they will come across. The only case I alpha 1-antitrypsin deficiency I have ever seen was in a rural primary care office.

You guys going on and on about how this step 1 knowledge separates us from PAs/NPs are delusional. Nurses and midlevels in this era constantly judge the lack of clinical acumen of many residents. It's part of the reason we get less respect than 20 years ago. You can recite the mechanism of ultra rare diseases. Cool. And maybe over the span of 10 years you'll make that one rare diagnosis. But... you look like a deer in the headlights as a resident when a nurse asks you what you want to do for a patient who isn't looking so good.

So we've gone from M3's not knowing enough about diabetes to nurses and midlevels judging the lack of clinical acumen in residents. Part of the reason this thread has gone sideways is that you have done an exceptionally poor job of articulating your argument. In UME we do actually debate the balance of emphasis on common versus rare disorders, so you missed an opportunity to have a productive discussion.

 

[efle]

To be fair, a decent amount of anatomy and other things you learn in first year that you likely care about, I've long since dumped into the deep recesses of my brain.

I think your second point is just wrong. The first two years have been about basic science forever, and the stress associated with the increasing importance of step 1 score is independent of that.

Obviously I don't know all of those off the top of my head, though I could tell you CYP3A4 metabolizes most chemo drugs. Again, the point isn't really the specific minutiae but the general concept. I think your underlying complaint still gets down to how important step 1 scoring is, which is valid, but has nothing to do with the value of what you're supposed to learn in MS1 and 2.

And that's the problem. The general concepts aren't what gets someone a step score competitive for whatever they want. Those minutia level details do. They have to ask about that ridiculous level of detail, because if they just asked someone to identify the CYP family as the major metabolizer of chemo, >90% of students would get it right and they'd lose all point-discriminatory capacity. For christ's sake they had to retire all their Step 1 practice forms and replace them with new much harder ones last year, because the average scores had climbed so ridiculously high.

As for my second point being right or wrong, I'm basing it off what I saw at my own school. The Genes To Society curriculum overhaul was recent enough (circa 2009) to be a great way to prep people for modern medicine on the wards, but not recent enough to be designed to teach-to-the-boards. The result was that Hopkins mean step scores were very average (234) around when I matriculated, and the result of that was that the students in years like my own began abandoning the curriculum to worship flashcards instead. It was very literally an overnight change in Zeitgeist that, in my opinion, was for the worse. But it worked; the curriculum and cohort GPA/MCAT both underwent no changes, and yet our scores jumped >10 points.

From the outside looking in, for anyone who did MS1-MS2 more than 5 years ago, we probably sound like a bunch of whiney babies upset that we have to learn some basic science fundamentals. But that's not it at all! We're upset at the arms race of minutia memorization that is consuming preclinical education.

 

[VA Hopeful Dr]

And that's the problem. The general concepts aren't what gets someone a step score competitive for whatever they want. Those minutia level details do. They have to ask about that ridiculous level of detail, because if they just asked someone to identify the CYP family as the major metabolizer of chemo, >90% of students would get it right and they'd lose all point-discriminatory capacity. For christ's sake they had to retire all their Step 1 practice forms and replace them with new much harder ones last year, because the average scores had climbed so ridiculously high.

As for my second point being right or wrong, I'm basing it off what I saw at my own school. The Genes To Society curriculum overhaul was recent enough (circa 2009) to be a great way to prep people for modern medicine on the wards, but not recent enough to be designed to teach-to-the-boards. The result was that Hopkins mean step scores were very average (234) around when I matriculated, and the result of that was that the students in years like my own began abandoning the curriculum to worship flashcards instead. It was very literally an overnight change in Zeitgeist that, in my opinion, was for the worse. But it worked; the curriculum and cohort GPA/MCAT both underwent no changes, and yet our scores jumped >10 points.

From the outside looking in, for anyone who did MS1-MS2 more than 5 years ago, we probably sound like a bunch of whiney babies upset that we have to learn some basic science fundamentals. But that's not it at all! We're upset at the arms race of minutia memorization that is consuming preclinical education.

Sound like the problem isn't the material so much as it is Step 1

 

[Lawpy]

And that's the problem. The general concepts aren't what gets someone a step score competitive for whatever they want. Those minutia level details do. They have to ask about that ridiculous level of detail, because if they just asked someone to identify the CYP family as the major metabolizer of chemo, >90% of students would get it right and they'd lose all point-discriminatory capacity. For christ's sake they had to retire all their Step 1 practice forms and replace them with new much harder ones last year, because the average scores had climbed so ridiculously high.

And i'm sad this happened because it made a lot of old Step 1 guides outdated. No joke but this change and absurd Step 1 mania make a compelling case to make Step 1 P/F.

 

[VA Hopeful Dr]

And i'm sad this happened because it made a lot of old Step 1 guides outdated. No joke but this change and absurd Step 1 mania make a compelling case to make Step 1 P/F.

It's almost like the powers that be wouldn't make a radical change without a reason.

Not saying making Step 1 p/f is good or bad, merely pointing out that it wouldn't even be up for discussion without a good reason.

 

[efle]

It's almost like the powers that be wouldn't make a radical change without a reason.

Not saying making Step 1 p/f is good or bad, merely pointing out that it wouldn't even be up for discussion without a good reason.

I'd phrase it even more strongly. NBME leadership would not be pretending to consider this change, unless the students and faculty experiencing it were calling it ruinous

 

[Dr. Doctor MD]

And that's the problem. The general concepts aren't what gets someone a step score competitive for whatever they want. Those minutia level details do. They have to ask about that ridiculous level of detail, because if they just asked someone to identify the CYP family as the major metabolizer of chemo, >90% of students would get it right and they'd lose all point-discriminatory capacity. For christ's sake they had to retire all their Step 1 practice forms and replace them with new much harder ones last year, because the average scores had climbed so ridiculously high.

As for my second point being right or wrong, I'm basing it off what I saw at my own school. The Genes To Society curriculum overhaul was recent enough (circa 2009) to be a great way to prep people for modern medicine on the wards, but not recent enough to be designed to teach-to-the-boards. The result was that Hopkins mean step scores were very average (234) around when I matriculated, and the result of that was that the students in years like my own began abandoning the curriculum to worship flashcards instead. It was very literally an overnight change in Zeitgeist that, in my opinion, was for the worse. But it worked; the curriculum and cohort GPA/MCAT both underwent no changes, and yet our scores jumped >10 points.

From the outside looking in, for anyone who did MS1-MS2 more than 5 years ago, we probably sound like a bunch of whiney babies upset that we have to learn some basic science fundamentals. But that's not it at all! We're upset at the arms race of minutia memorization that is consuming preclinical education.

I think I fundamentally disagree with your experience of Step 1 (which seems to be shaping your argument) despite the fact that our scores are probably very similar (95th+ percentile). I never touched Anki, I never memorized ridiculous tables and factoids that were irrelevant, and I focused on learning the big picture the first two years. There were few to no questions on step 1 where I had to regurgitate a gene/chromosome/enzyme or where I wished that I could flip back to page X in First Aid. Now, I'm not going to pretend that I didn't memorize some level of pointless minutia, but not nearly what you experienced or what the Anki cards seem to focus on.

Sure there were some dumb questions on Step 1 and some questions that were never covered anywhere, but those were few and far between. Most questions were testing your understanding of core concepts in novel clinical vignettes. I feel like you can still destroy step 1 with mostly a strong understanding of the material (85-90%) and a small amount of rote memorization (10-15%). I don't think you need to touch Anki to be in the 250-260+ range, nor do you need to memorize pointless tables with no relevance.

I've also seen way more examples of Anki fanatics who underperform terribly on step 1 at my school. Many more underperformers than overperformers from my experience. The only people who did well with Anki were the ones who were learning things correctly anyways and crushing the exams in MS1 and MS2. I will 100% agree with you that there is some really pointless stuff that needs to be learned (much of biochemistry) for step 1 but the idea that you need to cram thousands of cards is ridiculous. Also we have no real studies with Anki, we can't see how many people use it, how they use it, and what scores they get. We see an unrealistic filtered (instagram-esque) picture of Anki based on a few select individuals on SDN or in our classes, but almost never see or hear about the numerous people who use Anki with little to no success.

Things could have changed between the one year between when I took Step 1 and when you took it, but I highly doubt it. I agree with you that there is a good amount (~5-10%) of pointless garbage in FA, but the pressure to learn and understand all of the topics in FA prepared me incredibly well for third year. 95% of FA is awesome stuff that is the foundation of actual medicine, and learning it well is really important. I would argue that what separates a 245 from a 265 is not who can memorize more of the 5% FA crap, but who really understands and comprehends the other 95% that is important. So while FA and Anki pressure you to memorize copious useless minutia, I don't think Step 1 actually rewards this behavior as much as many think.

 

[efle]

I think I fundamentally disagree with your experience of Step 1 (which seems to be shaping your argument) despite the fact that our scores are probably very similar (95th+ percentile). I never touched Anki, I never memorized ridiculous tables and factoids that were irrelevant, and I focused on learning the big picture the first two years. There were few to no questions on step 1 where I had to regurgitate a gene/chromosome/enzyme or where I wished that I could flip back to page X in First Aid. Now, I'm not going to pretend that I didn't memorize some level of pointless minutia, but not nearly what you experienced or what the Anki cards seem to focus on.

Sure there were some dumb questions on Step 1 and some questions that were never covered anywhere, but those were few and far between. Most questions were testing your understanding of core concepts in novel clinical vignettes. I feel like you can still destroy step 1 with mostly a strong understanding of the material (85-90%) and a small amount of rote memorization (10-15%). I don't think you need to touch Anki to be in the 250-260+ range, nor do you need to memorize pointless tables with no relevance.

I've also seen way more examples of Anki fanatics who underperform terribly on step 1 at my school. Many more underperformers than overperformers from my experience. The only people who did well with Anki were the ones who were learning things correctly anyways and crushing the exams in MS1 and MS2. I will 100% agree with you that there is some really pointless stuff that needs to be learned (much of biochemistry) for step 1 but the idea that you need to cram thousands of cards is ridiculous. Also we have no real studies with Anki, we can't see how many people use it, how they use it, and what scores they get. We see an unrealistic filtered (instagram-esque) picture of Anki based on a few select individuals on SDN or in our classes, but almost never see or hear about the numerous people who use Anki with little to no success.

Things could have changed between the one year between when I took Step 1 and when you took it, but I highly doubt it. I agree with you that there is a good amount (~5-10%) of pointless garbage in FA, but the pressure to learn and understand all of the topics in FA prepared me incredibly well for third year. 95% of FA is awesome stuff that is the foundation of actual medicine, and learning it well is really important. I would argue that what separates a 245 from a 265 is not who can memorize more of the 5% FA crap, but who really understands and comprehends the other 95% that is important. So while FA and Anki pressure you to memorize copious useless minutia, I don't think Step 1 actually rewards this behavior as much as many think.

I'd say we were probably shaped off our classmates as much as our own experiences then. I agree that anki knowledge is not sufficient to score great, you also need to be a great test taker to start hitting that high range. But it absolutely is necessary. My school is full of top percentile test-takers who were very clearly being held back by their boards knowledge base. That's pretty well demonstrated by Hopkins having a 234 average the year I was starting when the norm was to study the GTS curriculum, jumping to 248 after the Anki wildfire spread. That's a sample size of >100 people who were all clearly not lacking in their ability to smash standardized exams.

The fact that you felt you didn't have to memorize much minutia for boards prep is a demonstration that either 1) your curriculum did a great job of teaching you that minutia (taught well to the boards, for example using NBMEs as unit final exams) or 2) you picked it up and retained it on your own just by a different means than anki. You absolutely did not walk into your test and score a 260+ without knowing a whole bunch of the First Aid tables' content that'll never come up again.

Edit: And I'd add that since the test is roughly scaled to 1 point per 1 question, even if we do say it's only 10-15% rote memorization, that's the difference between a 230 and a 258-272 for someone who has mastered the fundamentals. Seems to support the anki worship rather than refute it, assuming the student isn't going to be held back by their fundamentals and test-taking.

 

[GoSpursGo]

And that's the problem. The general concepts aren't what gets someone a step score competitive for whatever they want. Those minutia level details do.

I think we’re continuing to talk past each other. I’ve conceded repeatedly that the step 1 arms race is not a good thing, while maintaining that the underlying concepts are important to practicing medicine in the long term.

This whole idea that an MS3 or resident should be able to manage bread and butter diseases or presentations is what boggles my mind—that’s why they’re still in training.

 

[efle]

I think we’re continuing to talk past each other. I’ve conceded repeatedly that the step 1 arms race is not a good thing, while maintaining that the underlying concepts are important to practicing medicine in the long term.

This whole idea that an MS3 or resident should be able to manage bread and butter diseases or presentations is what boggles my mind—that’s why they’re still in training.

But doesn't it seem a little problematic for an exemplary preclinical student to arrive on Day 1 of their Medicine rotation and know all about the enzymes of hereditary metabolic disorders, and yet be clueless about what imaging or tests to order for all the common presentations? Trying to put together my Assessment&Plans for my patients was an absolute mess, despite having done a good job of learning what the national board says I should have learned. We can do all that learning later but why wait?

 

[7331poas]

But doesn't it seem a little problematic for an exemplary preclinical student to arrive on Day 1 of their Medicine rotation and know all about the enzymes of hereditary metabolic disorders, and yet be clueless about what imaging or tests to order for all the common presentations? Trying to put together my Assessment&Plans for my patients was an absolute mess, despite having done a good job of learning what the national board says I should have learned. We can do all that learning later but why wait?

Meh, maybe 10% of my education and time in medical school consisted of learning the krebs cycle. If we want to get rid of all biochem knowledge thats fine. But I don't see what is so valuable about adding an extra line to every First Aid section for "what imaging study would you order?". Especially since the answer to that question is changing every year.

 

[efle]

Meh, maybe 10% of my education and time in medical school consisted of learning the krebs cycle. If we want to get rid of all biochem knowledge thats fine. But I don't see what is so valuable about adding an extra line to every First Aid section for "what imaging study would you order?". Especially since the answer to that question is changing every year.

There's enough stable content in OnlineMedEd/Step 2 CK materials. One could easily trim a few months off preclinical and put in a new 12-week unit at the end of MS2 that's essentially A Crash Course in Actually Doing Medicine.

 

[Ho0v-man]

These arguments probably greatly hinge on what one considers to be minutiae in the first place. I didn’t think there was all that much minutiae at all on Step 1. But I also spent preclinical frantically preparing for what I thought would be a very out-of-left-field exam. I was surprised that 90-95% of Step 1 was pretty straightforward big picture stuff. I spent extra time on some questions re-reading thinking that surely this can’t be it. Most of my post exam anxiety was thinking I must not have read carefully and missed everything. Literally almost all of Step 1 prep has shown up in 3rd year save some biochem and all of embryo.

 

[efle]

These arguments probably greatly hinge on what one considers to be minutiae in the first place. I didn’t think there was all that much minutiae at all on Step 1. But I also spent preclinical frantically preparing for what I thought would be a very out-of-left-field exam. I was surprised that 90-95% of Step 1 was pretty straightforward big picture stuff. I spent extra time on some questions re-reading thinking that surely this can’t be it. Most of my post exam anxiety was thinking I must not have read carefully and missed everything. Literally almost all of Step 1 prep has shown up in 3rd year save some biochem and all of embryo.

Also hinges on what we think it means to be useful in 3rd year. I might be great and diagramming out all the different ways a heart can fail, but when I was asked what I wanted to do about it? Suddenly, it felt like knowing which drugs affect which part of the cardiac action potential was worthless trivia, and knowing actual diagnostic criteria and drug selection guidelines would've been time much better spent.

 

[ace_inhibitor111]

I'd say we were probably shaped off our classmates as much as our own experiences then. I agree that anki knowledge is not sufficient to score great, you also need to be a great test taker to start hitting that high range. But it absolutely is necessary. My school is full of top percentile test-takers who were very clearly being held back by their boards knowledge base. That's pretty well demonstrated by Hopkins having a 234 average the year I was starting when the norm was to study the GTS curriculum, jumping to 248 after the Anki wildfire spread. That's a sample size of >100 people who were all clearly not lacking in their ability to smash standardized exams.

The fact that you felt you didn't have to memorize much minutia for boards prep is a demonstration that either 1) your curriculum did a great job of teaching you that minutia (taught well to the boards, for example using NBMEs as unit final exams) or 2) you picked it up and retained it on your own just by a different means than anki. You absolutely did not walk into your test and score a 260+ without knowing a whole bunch of the First Aid tables' content that'll never come up again.

Edit: And I'd add that since the test is roughly scaled to 1 point per 1 question, even if we do say it's only 10-15% rote memorization, that's the difference between a 230 and a 258-272 for someone who has mastered the fundamentals. Seems to support the anki worship rather than refute it, assuming the student isn't going to be held back by their fundamentals and test-taking.

I think that has more to do with the effectiveness of Anki/UWorld in remembering information rather than some sort of huge discordance between what your professors teach and what’s tested on Step 1. Active learning, cased-based learning etc. is just more effective than passive learning of broad concepts.

You might argue that if this is the case why not have UWorld and Step 1 be focused on nitty gritty clinical information like the heparin nomogram or the ACS screening recommendations or something. But the fact of the matter is that specific management changes every few years depending on new research. Physicians are the ones that are the change agents in that respect and need to understand scientific data if they are going to make the rules. Any NP/PA can associate VEGF inhibitors with ovarian cancer without truly understanding how they work or applying them to new situations.