“Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.” –Aristotle.How to Excel on your Board Exams

Most doctors are very bright people. I believe that what often sets apart those who perform well on the job and on exams isn’t raw intelligence but rather the ability to learn effectively.

In the MCAT and USMLE steps 1, 2, and 3, I did poorly and barely passed. In 2009, I took my family medicine in-training exam and fell below the minimum passing score. After taking almost five years away from residency for healing and to run an orphanage in Africa, I returned to residency and quickly improved my performance to the level that I recently scored in the top 1% in the country on my in-training exam. My score isn’t the only thing that has seen a boost. I’ve won an outstanding resident award and very well clinically. As you know, it’s hard to sound humble writing about how you went from grass to grace, so please bear with me. A few of my colleagues have asked me to tell them what I’ve done to improve so quickly. This article is my attempt to share what I’ve learned in hopes of helping others move from good to great in their learning and patient care.

12 Ways to go from the bottom to top 1 percentile in your board exams

1. Don’t give yourself a worldview that frees you from the responsibility to do well on standardized exams. A lot of people who don’t have good scores on exams usually say, “I just don’t do well on standardized exams.” That statement right there condemns them forever to mediocrity on those exams. Others say, “exams don’t reflect my knowledge, I’d rather focus on caring for my patients and practicing good medicine.” When you do that, you give yourself a worldview that makes you a hero no matter what. We all know that standardized exams aren’t the best way in the world to measure knowledge. However, doing well on them is far from being a waste of time or something that happens by accident to those who are simply good test takers. If you prepare well, they can actually help you learn and become a better doctor.

Note: Watch your mindset. What you believe determines how you act and the way you live. If you don’t change the paradigm with which you view these exams, you would never improve on them.

2. Find out why you don’t do well on standardized tests and address it. For me, I simply read too slowly. Over the last two years, I’ve taken speed reading courses that have tremendously helped me improve my reading speed. And that has had a huge impact on my exam scores and my medical knowledge in general. I think this requires having a growth mindset that essentially says, “I can do everything that I need to do to succeed.

3. Develop a passion for learning. This is a skill that anyone can learn. Genuinely enjoy learning and love to learn for fun.

4. Learn how to learn. It’s very easy for someone who is going to medical school or who has graduated and is practicing to forget that they can improve their learning skills. For me, this is an area that I’ve fallen in love with and have taken several courses on how to learn. I’ve enjoyed using learning techniques like memory palaces, creating and using mnemonics, chunking, simple recall, spaced repetition, and testing myself.

5. Remember that understanding is different from remembering. We all know that, but remembering it is important. To be successful learners, we need both a strategy for understanding new information and a strategy for remembering and quickly recalling it when needed.

7. Become an active learner: Ask questions all the time. I’m confident that my colleagues would vote me as the person who asks the most questions during conferences and rounds. Sometimes, I’m afraid that people feel annoyed that my questions are taking too much time and I’ve sought to find a good balance. However, I think my questions are a secret to my dramatic improvement. I have to know why something is the way it is. I often wonder why some of my friends don’t ask questions even when a speaker has logical holes in what they are saying that need to be filled for someone to understand. I don’t think that I’m always the dumb person who doesn’t understand. I fear that either they aren’t following as closely or they choose to understand later or they are focused on letting the lecturer finish their presentation than they are on understanding immediately. Either of those would be a huge mistake. Many of us know that we won’t have time to revisit noon conference material. It’s better to ask questions to understand now. It’s better to cover 1 oz of material with full understanding now than a pound you hope to fully understand later.

8. Balance performance with preparation. At the beginning of my residency, I noticed that during our inpatient months, some of my colleagues were very focused on getting the work done that they weren’t putting enough effort to prod, question, and learn as they went along. I’ve trained myself to the point where I’m addicted to understanding before I am comfortable doing something, even if the attending physician instructs me to. So I found myself finishing a little later. Sometimes, when we were together, I could tell that others were feeling a little frustrated with my style of stopping and looking up sources to figure things out before moving on. It’s very easy to ask the attending physician to tell you what to do. To figure it out for yourself may take you a few more minutes. Now at the end of my second year, I’m so glad that I chose to proceed the way I did. Now, I’m quicker, more confident, and feel like I actually know what I’m doing and can cite sources to back my decisions. As a result, my attending physicians trust my judgment more.

9. Keep records. A habit that has helped me significantly is that at the end of the day or early the next morning, I type out what I learned the previous day into an assessment and plan format that I intend to use later. I put it on a blog I started for learning called upinhealth.com. I also read major textbooks and reference resources to make sure my assessment and plans are up to date. Then next time I see a similar case, I quickly go to my blog and in seconds I can review what I did before. On this blog, I also have uploaded common forms that I use in the clinic and the hospital and many learning resources. It’s my notebook that I can access at any time from anywhere. A blog is very easy to keep for that purpose. However, whether you use a blog or use one drive or google drive, it’s important to have a system for keeping notes for quick reference. The information in many textbooks is already one year old before the book is ever published. But in my practice notes stored on my blog, I update the information as soon as I see a new practice-changing guideline or research that is published.

10. Rest, sleep, and exercise. Stress, poor mental health, lack of sleep, and lack of exercise make memory consolidation and learning difficult. Find time in your busy schedule to sleep, rest, and get emotional first aid.

So far, I’ve focused on things that will help someone become a better learner. Many people who want to improve their scores on standardized tests are looking for a quick fix. The bad news is that there is no quick fix. Often, one has to develop new learning habits. That takes time and requires consistency. Below, I give advice specific to the test itself.

11. Study practice questions. Year-round, I study previous exam questions as a guide. The assumption is this: That the people who make those exams are sane enough to cover concepts on the exams that are actually relevant to the practice of family medicine nationally. We know that geographic location, patient population, seasons, etc, affect the kind disease processes we see in our practices and so learn from. I don’t try to use those exam questions to study simply to prepare for the next exam but rather see the cases addressed, read about them, check out the most current recommendations, understand the pathophysiology, treatment approaches etc. After doing that, I go to my notes on my blog and create an assessment and plan that pretends that I actually had a patient like that in my hospital or clinic. I go over what I would do to take care of them. By doing this, one becomes familiar with the way the examination writers think but without limiting oneself to preparing for an exam. I actually think I’m a better clinician today because of this approach to studying exam questions.

12.Take a full-length practice exam. I’ve found that taking a full-length examination several weeks before the real exam helps you with endurance and pacing. If you struggle to finish on exams, try that.