The Hidden Danger of Mixed USMLE Practice Questions

Why is USMLE preparation dogma ruining your progress?

“Do thousands of questions and memorize the First Aid”…

That was the USMLE Step 1 prep advice laid out by my school.

That advice, quite honestly, sucked—but it was treated as dogma.

Just do it, they’d say… It’s how it’s done.

No explanation for why this is the way things should be done…

No specifics about how to properly navigate questions…

And not a shred of advice for what to do if—or more likely when—you hit a roadblock.

Plow through questions…

Up to ten thousand if possible…

And memorize the First Aid—if you do that, you’ll be fine.

Not only did this fail to work for me, it slowed me down for months.

NBME after NBME showed little to no progress…

At one point, I thought perhaps I didn’t have what it took to make it.

Maybe I was among the unlucky few who’d be plucked from the system at the hands of the punishing USMLE Step 1 exam.

But I don’t give up easily… I’d seen people with half my work ethic crush this thing, so why not me?

I re-examined the entire USMLE prep process from scratch—my future depended on it.

I finally figured out what worked for a student like me—slow to learn with weak test-taking skills—and was able to move forward.

Unfortunately…

That steaming pile of excrement my school’s “Guidance department” gave me remained dogma for the next fifteen years.

After graduation, I started my first USMLE prep company to help medical students like me better prepare themselves for the exams.

The bad advice, unfortunately, lived on for years…

Until…

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Fast-forward fifteen years…

There’s a new dogma in town…

And boy, oh boy, is it a doozy!

Today's advice spread through Reddit faster than syphilis through old folks’ home.

“Doing mixed USMLE practice questions—and lots of ‘em—is the only way to succeed.”

Whether with UWorld, Amboss, or any other Qbank, today’s widespread advice is to do mixed USMLE practice questions right out of the gate.

Whether you’re a brand new basic sciences grad or are getting back into things after a long sabbatical… Mixed questions are the Holy Gospel, according to Redditors.

Of course, those parroting this advice surely outline the nuances of this strategy… right? 🤔

I’m certain they mention that this strategy won’t work for you if your foundation is weak… right? 🙄

And surely they provide an alternative solution for those who’ve been out of the basic sciences for a few years and will become lost and frustrated… right? 🤨

Yeah, right—and that’s the problem.

A blanket piece of advice doesn’t work for everyone; not with USMLE preparation or anything else. But if this isn’t pointed out, those desperate for help will end up following a path more likely to cause frustration rather than success.

So… What to do… What… To… Do…

The answer is to examine and dissect this advice to understand why it’s not right for everyone.

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WHY MIXED PRACTICE Qs HURT PROGRESS…

It comes down to the strength of one’s fundamentals—seriously.

That’s the core problem underlying this strategy.

If you’ve got a strong grasp on the fundamentals, then by all means, dive into mixed questions from the start—you’ll probably be fine.

But if you don’t, starting with mixed questions may cause more harm than good.

Let's use a visual to better understand why mixed questions can be harmful if you don’t have a solid grasp of the fundamentals…

The Starting Point: The “Big Picture” is the concept/idea behind the question… The “Fundamentals,” represented below by a group of letters, represent an entire topic/subject (ex. A = Histology, B = Anatomy, etc).

To increase our chances of correctly answering a USMLE question, we’ll need the ability to pull from different disciplines quickly and precisely. If the “big picture” below is a “connect the dots” drawing, we’ll need to know where to place the letters to see the “big picture” with clarity.

Each question/vignette paints a vague picture of the scenario at hand…

The picture must be clear and obvious to arrive at the correct answer—or at least give us a good chance of making an educated guess.

In the example above, our “big picture” takes on a basic shape, but it’s far too vague to make any sense. We must use the information in the vignette to better understand the scenario.

We do this by connecting a handful of puzzle pieces—like a “connect the dots” image.

This is only possible, at scale, if our entire body of knowledge is rock-solid.

If we start mixing questions before our foundation is in place, it becomes nearly impossible to put the pieces in their correct order (like the image below).

Mixing practice questions too early scatters your learning...

Sure, you’ll be able to fill in some of the pieces (circled letters), but things are still too blurry—we can't connect everything to make sense, solve the puzzle, or connect the dots.

Let’s say, as an example, this is a question testing our understanding of urinary incontinence…

If you have yet to master the bladder’s anatomy, physiology, and receptor types, a seemingly simple question about overflow incontinence becomes unnecessarily difficult.

If this was the first question encountered as you began doing mixed practice questions, you’re likely to make a mistake and feel that your knowledge is lacking—which it is!

Then, you’ll memorize random facts from this question out of context:

• The bladder is rich in M3 receptors

• M3 antagonists for urge, M3 agonists for overflow

• Bladder outlet obstruction is a common cause of overflow

• Etc, etc.

It’s great that you’re learning these facts… They are important!

But they’re not learned within the context of their main subject, which means you lack context on how to apply them elsewhere…

Then you’ll go to the next question, which could be about nearly anything, and you’ll once again be stuck trying to memorize random facts with no sense of cohesiveness.

Had you learned everything about the bladder all at once (i.e., a systems-based approach), you’d be well-equipped to handle any number of bladder pathology-related questions. But you didn’t. Your learning is all over the place, and you’re becoming increasingly frustrated with each additional question.

You’re unable to make connections…

You’re unable to see patterns…

And you’re increasingly confused the more you cover.

Building a strong foundation upon which you can accumulate and solidify your knowledge becomes nearly impossible when learning occurs in a random, non-sensical way.

What if, instead, we started our practice questions with the basics… One topic at a time?

Anatomy first… You do all the available anatomy questions and build a rock-solid foundation—giving you a strong, well-rounded understanding of anatomy.

You’ll understand how things work individually and how they’re connected…

You’ll be better equipped to take your knowledge and plug it into any USMLE question that requires an understanding of anatomy.

Then you cover histology… Again, you learn the fundamentals of histology while building on top of your anatomy knowledge.

The same approach is continued with each topic until you’ve got a strong overall base and begin to see the connections between different disciplines and systems.

When you tackle USMLE practice questions in this manner, you build the foundational elements of success… This will help you get more out of mixed questions when you start adding them to the mix (which you can do once you feel somewhat competent across all disciplines).

With a strong foundation, you can dive into mixed questions, apply what you know, determine where you lack knowledge, and make the necessary improvements. This approach is far superior to accumulating random facts and praying to the heavens that you can figure out how it all ties together at some point along the journey.

Once you’ve mastered the fundamentals, you can return to that question, and suddenly, things fit together nicely and neatly (see below).

With a strong foundation, the puzzle pieces fit together…

And the “big picture” is crystal clear.

Then, you can fill in some details for an even higher-definition picture.

Mixing practice questions scatters your learning... Leading to confusion and frustration.

Topic-focused questions build a foundation… Giving you the skills needed to attack questions with confidence and accuracy.

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KEY TAKEAWAYS:

• Mixing questions is how you challenge your knowledge.

• You can’t challenge knowledge that doesn’t exist.

• If you're mixing practice questions and struggling to progress, go back to topic-specific blocks of questions.

• When you’ve built a solid foundation across all subject areas, begin mixing questions to test and challenge yourself.

If your goal is to improve as quickly as possible… Determine which starting strategy is right for you and commit to going all-in.

Master one topic at a time... Then, mix things up to challenge yourself!

That’s it for me… Good luck!