![]() ![]() Interestingly, there were no questions on renal tubular acidosis on my exam. Despite this, I was aware that the effort I put into studying it or the mental energy I invested would likely yield a smaller return in terms of increased scores or a less substantial outcome than reviewing epidemiological equations again. One day before Step 2, for example, I realized that if there was a question on renal tubular acidosis, I would get it wrong. When I began unnecessarily cramming facts that I already knew for Step 1, my marginal cost exceeded my marginal revenue, and the profitability of my efforts began to fall. In fact, firms that maximize profitability are those that set their marginal revenue, or the incremental gain from producing one additional unit, equal to their marginal cost or the incremental loss associated with that production. Commonly known as the law of diminishing returns, this economic principle teaches that to maximize productivity and keep costs low, firms should produce up to this point but not past it, as the costs associated with producing that unit exceed the revenue that could be generated from selling it. In the production process of every product or service, there comes a point at which adding an additional unit of input to the system actually leads to a smaller output, or return, per unit of input. It was not until several months later when I was reading for a master of business administration (MBA) economics course, that I realized the principle underlying my differential success in preparing for Step 1 versus Step 2. When I received my score, my instincts were confirmed. When I walked into the same lifeless examination room, I knew in my heart this time that it was all in my head. There was no time to waste reviewing what I already knew for the sake of confidence. I completed practice questions only on the social science materials that had faded into the depths of my temporal lobes since prepping them a year prior for Step 1. But I knew my scores on the practice exams, and I knew that the time I had spent participating in the clinical side would pay dividends for my own learning style, dividends I would not have acquired had I decided to answer flashcards on rounds instead of focusing upon the plan for each patient.įor those ten days, I took one practice test and read over notes from the questions I had missed on clerkship practice exams over the past academic year. When I told my friends how I was preparing, they seemed concerned and touted their own strategies. I studied for my patients, read medical news articles that pertained to my rotations, and paid focused attention in didactics and on rounds. I then decided to take the road less traveled and ditch the study tools that had become a task rather than a benefit and those whose interfaces didn’t promote my personal learning style. In the weeks since I took Step 1 and received my score, I reflected on the unhappiness, anxiety, and imposter syndrome that clouded my acquisition of new facts leading up to test day. ![]() Soon enough, it was time to begin structured studying again, this time for the NBME subject exam that ominously waits after each third-year clerkship. My score was enough, sure, even more than enough to be considered competitive, but I think I speak for most of my fellow colleagues in the profession of medicine in saying that enough will never be enough for us only our absolute best will ever be sufficient. So much stake was placed on a single day, only to underperform. The truth, however, is that upon leaving that lifeless examination room, I knew that the time I had spent dutifully preparing for that day over the past many years had been diminished by a “dedicated study period” that I had instead dedicated to over-preparing and perseverating on perceived weaknesses. I’m not here to share the narrative of a poor Step 1 experience or lament what could have been. It was almost as if with each new fact I discovered and reviewed, I dreaded studying more and more for fear that I would uncover more gaps in my knowledge. The new facts began to muddy the clarity of the concepts I had already mastered. Yet with every new piece of information, I tried to cram into my head, every enzyme on the protein synthesis pathway that I swore would give me the competitive advantage, I pushed myself further into doubting all of that previous work. Strong enough to the point, in fact, that I refused to believe it. The practice tests revealed that I was in a strong position for success. The question banks had been answered, and the Anki cards had been strategically reviewed. When my internal dialogue repeated those words, they took on a different meaning. When my friends, family, and mentors said these five words to me in the days leading up to the pre-pass/fail USMLE Step 1 exam, they meant it literally: everything you need to know to succeed is already in your head. ![]()
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