Start Early and Do Lots of Questions: Acing COMLEX and USMLE Prep

By Ryan Nguyen

Many osteopathic medical students at the beginning of their second year struggle to come up with a game-plan to prepare for the COMLEX Level 1 and USMLE Step 1. With a disturbing number of resources and study plans to choose from, how can students determine what strategy will maximize their board scores?

Early in my second year, I scoured the depths of the internet pouring over the study schedules and tips of past test takers. I was looking for “the one,” a study schedule that would get me the scores of my dreams. The dirty secret to success? There was no one study plan that triumphs above all. While they all varied in their day-to-day plans, study plans from top scorers all echoed the same two principles: start preparation early and do lots and lots of practice questions.

This post is dedicated to when to start preparing and how many practice questions to do.

A 2013 paper from Nova Southeastern University analyzed the COMLEX study habits of 122 third-year students and sought to identify the predictors of scoring a 600 or higher (roughly greater than the 83rd percentile in 2012). While those with a COMLEX above 600 were 1.4 times more likely to have a higher preclinical GPA and 1.3 times more likely to have a higher MCAT, they were 2.5 times more likely to have initiated examination preparation earlier than those who had scores less than 600.

Removing preclinical GPA and MCAT scores from the equation, those who scored above 600 were 2.9 times more likely to have started studying earlier than those with lower scores. While the study broke down start of exam preparation into first year (5.4%), September to December of second year (15.2%), January to March of second year (34.8%) and April to May of second year (44.6%), there was no conclusion as to the optimal time to start preparation or when to start specific materials.

Given that starting studying earlier is associated with higher board scores, when exactly should you start?

My suggestion is to ideally start preparation between September to December of second year and no later than January to March of second year. Preparation in the first semester of second year allows students to get comfortable with the school-relevant sections of First Aid alongside classes while also getting early practice question exposure. For example, during my fall semester Endocrine, Cardiovascular, and Renal classes, I would become familiar with the matching First Aid sections as well as do practice questions for those specific topics. Since I was already comfortable with First Aid’s format and studying from practice questions by January, I could then begin reviewing material that fell outside my class schedule.Come dedicated board studying time in May, I already had a thorough pass of First Aid and thousands of practice questions under my belt.

Speaking of questions, just how important are doing practice questions to scoring high on boards? An analysis of the 2013 class at the Albert Einstein College of Medicine, found students completed an average of 2,850 questions (SD=919). Controlling for academic variation and motivation, the study designers found a one-point increase in USMLE score per 100 questions completed. By this study’s design, the difference between a 228 and a 250 on the USMLE Step 1 correlates roughly to a difference of 2,200 practice questions. While a gross oversimplification of the correlation between practice questions and board scores at the higher end (simply doing 8,000 practice questions in no way guarantees a 260), it should come as no surprise that top scorers go through more practice questions than those who score lower.
So just how many questions should you complete?

I suggest 4,000 questions as the minimum number of practice questions to have done before test day – 6,000 questions for those aiming for higher scores. This includes one or two complete passes of a question bank along with review of incorrects, a separate pass of an additional USMLE-focused question bank, and select questions from a COMLEX-specific question bank.

Simply put, there are only so many ways to ask questions on thyroid disorders, antiarrhytmia drugs, and viscerosomatic points. Going through thousands and thousands of questions gives students the exposure necessary to see how these topics present in a multiple-choice format. Having gone over 6,000 questions by test day, I felt very comfortable identifying similar question formats and trap answers on both USMLE and COMLEX test day. There were even multiple questions on both exams that had been asked in nearly identical ways to practice questions.
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