Congratulations on finishing 5th term. You are officially done with the basic
sciences and have one last hurdle before beginning your clinical training. The USMLE Step 1 exam may seem daunting at
first. I remember constantly questioning
myself…where do I even begin…am I going about this the correct way? I must admit that this exam seemed
insurmountable at first glance but after breaking it down into tiny digestible
chunks, I believe the entire process, although challenging, is completely
manageable…and dare I say it…rewarding. Treating the Step like a marathon instead of a sprint, will not only
keep you sane, but will also improve your self-discipline, morale, and overall
retention span of the hard-earned knowledge.
Here is my personal journey of preparing and studying for the USMLE Step
Focused studying dates: May 26 – July 24 (~ 8 weeks)
Date of examination: July 25
Results received: August 14 (~ 3 weeks)
Doctors in Training – 2013 (~ 2.5 weeks)
Main review books
First Aid for the USMLE Step 1 2013
Pathoma – Fundamentals of Pathology
BRS Physiology 5e
Rapid Review Pathology 3e
High-Yield Biostatistics 3e
Kaplan USMLE Medical Ethics – 100 Cases You Are Most Likely To See On The Exam
BRS Behavioral Science 5e
High-Yield Neuroanatomy 4e
Clinical Microbiology Made Ridiculously Simple 5e
Supplemental review material
NBME Self-Assessment (7: 221, 12: 231, 13: 235)
USMLE World Self-Assessment (1: 244, 2: 244)
Prometric USMLE Step 1 Practice Test (89%)
In the beginning of term 5, I spent a little over 1.5 months learning
microbiology. I believe I came down with
dengue fever a month before the second pathology midterm and the microbiology
final. I was not able to study the material since I was in so much pain but knew I eventually needed to master the subject. I read Clinical Microbiology Made
Ridiculously Simple (CMMRS) cover to cover in order to understand
microbiology. CMMRS was well-written in a
cohesive and organized fashion. This
book brought depth and meaning to each bacteria / virus and I wasn't simply
memorizing list of information. The only
issue I had was the sheer volume of all the different microbial pathogens and
drugs. I understood the material but had difficulty categorizing them in my head.
That was where Picmonic saved my behind.
This website contains pictures of numerous topics with silly
stories that I felt were helpful in remembering key attributes of a bacteria /
virus and antibiotics (I also used it for neurocutaneous diseases like
Sturge-Weber syndrome, and enzymatic deficiencies like Fabry disease). I would read in CMMRS about XYZ to learn the
information and then I would use Picmonic to memorize said material.
Whenever I was on break, walking to the bus stop or waiting
for the bus (I studied in the library and lived off campus), I would pull out
my iPod and listen to Goljan. This guy was really, really good. I loved how he
tied in subjects together and made them clinically relevant. If I could go back, I would have listened to his
lectures another time. I highly suggest
you grab yourself a copy of his audio and listen to them.
I spent a decent portion of my time each day in term 5
reading First Aid (FA). I finished the
book cover to cover two times by the end of the term (minus the microbiology
section on my first go-around). I also
used Pathoma (which was heavily annotated in term 4 because I did not want to
watch the videos again or look at any of the pathology notes from class) concurrently
with BRS Physiology to complement each chapter of FA. I would first read BRS Physiology, followed
by Pathoma, and then finally read the corresponding chapter in FA. I found this method helpful in hammering my
understanding of the subject matter. BRS
Physiology provided a conceptual basis for my learning; Pathoma would simplify
the pathology of diseases and made them easier to digest and comprehend; First Aid pooled
together these two resources along with my previous knowledge into an organized
fashion. I felt this combination allowed
for an optimal mixture of content and provided a strong skeletal framework in my
mind and on paper.
I would do USMLE World (UW) questions after finishing reading
about a topic in its entirety in BRS Physiology, Pathoma, and FA. The questions I chose related specifically to
the subject matter. For instance, if I
were reading on nephrology from said material, I would only do questions from
nephrology in UW (select all for main divisions, select renal in sub divisions). I decided to do this because it would make
annotating everything into FA much easier…I didn’t have to constantly flip
around to find an area to write my notes.
One thing I don’t believe was in saving question banks. I heard a lot of students doing that, saying
they wanted to save the best questions for last since it most closely reflected
the actual Step. In my humble opinion, I
don’t think this is the correct approach.
You will learn so much from doing UW questions since it forces you to
synthesize information in a way one never thought of. It also allows you to discover your weakness
and provides ample time to strengthen them.
There is simply not enough time to tie all the information together if
you were doing these questions toward the end of your studies.
USMLE World Cumulative Performance
I started with 10 UW questions at a time and eventually progressed onto doing a complete block. I would do untimed, unused questions only. After answering the questions, I would briefly look over each one and mark the incorrect questions and the ones I got correct but didn’t truly understand. I think that last point is extremely important. It is not enough to simply get a correct answer and move on. You have to understand why it’s correct, but more importantly, why each of the other answer choices is incorrect. The reason I always did a quick look through of all my questions was because annotating took me a long, long, time. It would sometimes take 2 days before I would get a chance to completely annotate all the information from the UW questions into FA. I would spend roughly 1 hour for 4 – 6 questions max. Sometimes I would dig deeper into a specific topic that I did not fully comprehend. I would look into Robbins Pathology, Wikipedia, research articles, and books I’ve used in previous terms. That was why I wanted to at least read the summary to remember that question prior to annotating it a couple of days later. This process was extremely tedious, but I felt that writing the information down helped in my learning.
I had initially decided to stay in Grenada because I had a
specific routine that I adhered to on a daily basis. However, toward the end of term 5, I longed
to be in the comfort of my own home and desperately wanted to take a bite out
of the succulent burgers and fries at In-N-Out.
After leaving Grenada for the last time I needed a mental break. I gave myself a little over a week to relax
and recuperate before I began the marathon that is Step 1.
I strongly believe that preparation for this examination
begins during the first day of school and that your Step 1 studying, for the
most part, should be a review of things learned along the way. I personally would find it difficult to fully
comprehend and master 5 terms worth of knowledge in such a short span of time.
One of the most crucial factors I think in preparing for the
Step is to find your own study space. Be
it a coffee shop, bookstore, library, school, or home…you need to find a stable
place that remains open during your allotted study time, has internet
availability, easy access to food and restrooms, and that you could go to
without much hassle. You don’t want to have
this variable lingering in your mind each day before beginning your
The next thing I did after finding my study area (home) was
to take NBME 7 as a baseline of my current standings. This practice exam gave me an opportunity to
gauge my strengths and weakness and also allowed me to set a realistic goal for
my Step 1 score. I would look online at
StudentDoctor or USMLE-forums to get answers to the questions I got
incorrect. On a side note, I suggest you
don’t browse other threads that talk about their outcomes on StudentDoctor during your studies. Everyone on there has a 260+ and it does
nothing for your confidence or morale. It
took about a day or so to annotate the answers into First Aid. You could view the incorrect questions if you
purchased the expanded feedback option available for NBME 6, 7, 11, 12, 14, and
I proceeded to make a study schedule after taking my baseline practice examination. This is so, so important. Take some time to think about how you want to organize your schedule. Some people I’ve talk to used an organ-based approach, and others chose a subject-based approach. Take the time to evaluate your strengths and weakness prior to writing down your schedule. Allocate more time to your weaker subjects and less to your stronger ones. However, I think it would be wise to spend some additional time on cardiology and neurology, even if they happen to be your strengths.
If you are making your schedule subject-based, I suggest you place topics that are more conceptual towards the beginning half. Topics with more rote memorization should be placed towards the second half of your studies. The reason I think this approach works is because conceptual knowledge takes time to understand...and if you have these subjects in the beginning, then it allows more time for your brain to digest the information. Subjects that require more memorization vs understanding, should be placed towards the end because recalling these facts would be easier since you have just studied it. Either way, you should spend some quality time in making your own schedule...don't blindly follow and copy others. Only you know your own strengths and weakness...no one else does.
I initially scheduled my exam date for 7 weeks after studying (more on that later). Try your best to not deviate too much from your schedule…you’ve spent a lot of time thinking about your course of action, what’s the point in doing that if you aren't going to adhere to it. But...if you know for certain that you could benefit from some more time...adjust accordingly. Just know that after a certain length of time, your score will plateau and could possibly begin to dip.
I purchased a review course early on because I needed some
structure to my studies. I decided to
get Doctors In Training (DIT) because it was the shortest and I read good
reviews about the program. If you do
decide to get DIT, I highly recommend that you follow along with the workbook
(pre-video questions and pop quizzes).
This is of paramount importance because it further reinforces ideas, forces
you to write them down, and to think about details you would normally gloss
over. I ended up spending more time than
I wanted because I would annotate notes along with the videos into FA. I honestly think that DIT helped me go
over each subject in FA a third time. I would
at times find myself making the mistake of focusing on my stronger subjects and
studying those instead of my weaker ones (confidence booster!).
DIT forced me to study my weaker subjects (biochemistry) with even weight
as my stronger subjects.
I personally found that DIT was enjoyable but it was not without flaws. I felt they gave a little too
much detail in certain topics and simply glazed over others which deserved
more. They would spout off lists of
things they felt were important but would not emphasize which ones were key
facts to know. I found about a dozen
mistakes made throughout the videos and e-mailed them about those. When I asked the support staff for a list of
errors, I was informed they would make the changes in the video but would not provide an errata sheet for subscription members. I found this extremely troubling and frustrating because I did
not know if previous videos I had watched contained errors. I began spending additional time towards the last third of the course looking
for mistakes and finding them. Another gripe I had with DIT was the lecturers. There were a couple high
caliber instructors in the course but I found some to be lacking in enthusiasm,
knowledge, and knew they were simply reading straight off slides. Looking back, I probably would have done the
course again despite these major flaws.
I had to remake my schedule after finishing the DIT course
because it took longer than expected. I
began each day with doing a block of random timed UW questions followed by reading
over the answers. I think doing random
timed UW questions gives a better representation of the actual Step. This trains you to read and synthesize the
information quickly and to switch gears rapidly from topic to topic. After doing a block of questions, I would
read Pathoma, BRS physio, the corresponding topic in FA, and my annotations in these review
books. I would finish each day doing
another block of random timed UW questions.
I started falling behind a little after a week of adhering
to this format. For instance, it took me
a little more than a day to completely review psychiatry instead of a half-day
I allotted to it. Similarly, cardiology
and neurology took a little more than 3 days to review instead of the 2 ½ days that I
anticipated. Consequently, I looked at
my schedule and knew I did not have enough time to cover all the topics
adequately. I decided to push my exam
date a week later than my intended date.
This gave me some breathing room and drastically decreased my
I did not set my study schedule according to the number of
hours I would put in each day; rather I decided early on that I would need to
get through a set amount of material before I called it quits (more difficult
than it sounds). I would often take
about 3 hours in the morning doing questions and reviewing. I’d then take a 30 minute break and began
studying for that day’s topic. I would
stop at lunchtime and take exactly 60 minutes to eat and relax. After lunch, I’d continue until roughly an two or three hours past midnight (I work best at night).
About 10 days before your Step 1, I suggest you begin having a regular sleeping
schedule where you wake up a few hours before your exam time and get around 7 -
8 hours of sleep per night. The reason
you want to wake up a few hours before is to lose any grogginess you might have
in the morning and to give your mind time to fully awaken. You want to walk into the exam at a hundred
and ten percent and you aren’t going to do that if you’ve just rolled out of
Comparing UW to NBME questions in terms of the learning potential, I
believe UW gives a better bang for your time because UW has actual explanations
whereas NBME only displays your incorrect questions without answers or
explanations. For this reason, I knew I
had to utilize the UW self-assessment (UWSA) 1 and 2 early on instead of at the
tail-end of my study. NBME provided a
gauge to my score and UWSA provided further insight into ways questions could
be worded. Reviewing UWSA took me about
3 days since I wanted to annotate answers into FA. I made the mistake of taking UWSA 2 at
midnight to prevent myself from falling too far behind. I don’t suggest you do that because you won’t
be on you’re A-game. I also suggest
taking your practice exams the same time your actual Step is scheduled. That way your mind and body would be more conditioned
for examinations at that given time (I only did UWSA 2 at an unusual time, the
rest were at 1 pm). Reviewing the NBME
took about one and a half day. I will
say this however…I had a couple of questions on the actual Step that I would
not have ever gotten if I did not review the NBME practice examinations. For example, regeneration of muscle fibers
showing fiber grouping after muscle is denervated. I had never learned about this concept and
would not have read about it if I had not reviewed my NBME practice
I would sometimes come across questions in the UWSA or NBME where I could not reason out the answers. Even after looking through FA, Pathoma, BRS physio...I sometimes would still be at a loss. I found that Rapid Review Pathology by Goljan helped tremendously in these scenarios. I sometimes wish I had also read Rapid Review in its entirety during 4th term pathology. However, given the choice between Rapid Review and Pathoma, I would choose Pathoma hands down. There aren't as much details in Pathoma compared to Rapid Review, but I think that can be a plus. In Rapid Review, although the information in there is gold, there is just too much details to remember. In Pathoma, pathology is sometimes a little simplified, but on the flip side, it makes them easier to recall. Plus the brevity in Pathoma allows for a much quicker review. Having said that, I think Rapid Review would be a great tool to have for understanding how and why things occur.
The biostatistics section in FA was lacking in content. High-Yield biostatistics more than made up for the slack. This review book was a quick read and contains most of the information you need to know for biostatistics. I had used this book in third term, so flipping through it didn't take very long. I also found the ethics section from that same chapter in FA was lacking in substance. I used Kaplan USMLE Medical Ethics by Conrad Fisher to enhance my understanding of medical ethics. This book was very short and should take no more than a few hours to get through. The format of this book was very effective at teaching ethics. The first half of the book explained the basic principles of medical ethics. The second portion had various cases which incorporated ethics into clinical scenarios. I used the answer section at the end of the book as my review for ethics. It briefly summarizes why you should answer XYZ vs ZYX. You can get through your ethics review by reading the answer section since it highlights all the main concepts.
I know some students chose not to focus too much time on biostats and ethics...and I totally understand why. But in reality, you will miss more than a couple of easy questions because you didn't spend time to review. I had some questions which incorporated ethics and biochemistry into one question. I can guarantee that I would not have felt confident in my answer if my knowledge was lacking in either of those subjects. The same can be said of biostats. I had a few questions that tied together biostats, biochem, and genetics. Basically, what I'm saying is...it wouldn't hurt you to spend a couple of hours reviewing biostats and ethics.
BRS Behavioral Sciences was another book I glanced through for certain topics only. I did not read this book from cover to cover. I think the developmental section in FA was not adequate for certain questions. I don't have this book with me right now so I can't remember off the top of my head what else I used it for.
High-Yield Neuroanatomy did a fantastic job in teaching me the neural tracts. Again...I don't have this book with me right now...but I remember using it for that purpose. I also used it for explaining functions of various parts of the neurological system. This was a short book and easy read. I would suggest using this book if you have trouble with neural tracts.
If you have time towards the end of the studies, I strongly
suggest you sign up to take a Prometric USMLE Step 1 Practice Test. There was a little over 120 questions and it
took about 3 hours to complete. The benefit in doing this is not for the
questions itself or as an estimate of score.
The format was different than the actual Step and the questions were too
easy (I scored 89%). You also didn’t get
any explanations for the questions. The
benefit in taking this practice exam at Prometric was to make sure you have all
the documents in order, but most importantly, to get used to the surroundings. You don’t want to walk into an unfamiliar
environment to take one of the most important examinations of your life. You want to know what the temperature is
like, noise level of surrounding area, space allocated for your food, where
restrooms are located, where to request your computer station (I suggest away
from the door), how the seats feel, and all the ins and outs of the place so
there would be no surprises when you arrive for game day.
I also purchased USMLE-Rx (Rx) and used it periodically in
the mornings or at night when I wanted something quick and easy. I did less than 25 percent of the questions so
I can’t really comment on the utility of this in comparison to UW. I did however use Rx on D-Day as a way to rev
up my brain prior to the actual step.
What I did was go through 25 random timed questions without thinking too,
too hard to get my brain going and…this is very important, without
looking to see if I got the correct answer.
What if you ended up getting a bad percentile on your dry run? You do not want to go into your exam carrying
that excess mental baggage. I can only imagine
that it would be demoralizing and could affect your confidence level and thus your performance.
A couple of days before my Step, I began regulating what I
would eat (mostly a bland diet of ramen, eggs, and fruits). I didn’t want any GI issues come exam
time. I also suggest you look through
the tutorial on usmle.org so you can save yourself 15 minutes
and use it for breaks. The things I would
do during the tutorial were adjust my seat, adjust the monitor for brightness
and contrasts, and check to make sure the headphones were working and that the
proper volume was set. I also schedule out
my breaks for this exam. My personal preference
was blocks 1,2 -> 15-min break -> blocks 3,4 -> 17-min break ->
blocks 5,6 -> remaining time left over -> block 7.
I felt the actual USMLE Step 1 was more difficult than
UWSA and NBME practice examinations. One thing I must mention is that UW's layout is exactly the same as the actual Step. It seriously felt like I was at home doing another another block of questions. The only difference was that stems were a lot longer and at least for my examination, almost
every question had lab values (either pertinent or not in understanding the case).
I strongly suggest you learn the most common lab values given in
FA. This decreases the time spent
browsing for values and allows for more efficient use of your time. I also strongly suggest that you memorize
down cold all the equations given in FA.
You should also learn all the various graphs, diagrams, and charts in FA
and think about the outcomes after manipulating the variables. You need to know the pathways for
biochemistry. I had a few questions that
consisted of blank boxes with arrows and to understand the question, I
had to know either the enzymes or the products.
I suggest that you pace yourself throughout the exam and don’t spend too
long on a question if you get stuck. I
know either 50 questions are peppered throughout the exam or an entire block
consists of experimental questions. That
means a potential question you could be spending your precious time on doesn't
even count. In that scenario, if the
question is too difficult, just make an educated guess and move on. You must make sure you get through all the
questions prior to going back and answering your marked and/or difficult questions. I had a couple of blocks where the last few
questions were easy points and I could see how one would be at a disadvantage
if too much time was spent on prior questions.
In the end, I think that USMLE Step 1 was an intense but
extremely rewarding journey. I dug deep
within myself to find the courage each morning to wake up, do another set of
questions, study, do more questions…rinse…repeat. There were times I felt somewhat depressed…I didn't
step foot outside of my house the entire time and I asked Katherine (my wife)
and Gunther (my best friend and dog) to be with her family for the time
being. I didn’t get to exercise (I
suggest you get some cardio), and I completely shut myself from the outside
world and didn't get to spend time with my friends and family. I had my moments of self-doubt, low morale,
and mild depression. In the end however,
I thought the vast amounts of knowledge I had gained about medicine...but more
importantly, the knowledge gained about my own character, was well worth the sacrifices made. I wish you all the best in your USMLE Step 1 endeavors. Please message me if you have any questions. I will be more than happy to help. Now go get 'em Tiger~!
NRMP - Charting Outcomes in the Match - International Medical Graduates (January 2014)