My Personal USMLE Step 1 Experience

Congratulations on finishing 5^th 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 1 examination.

Focused studying dates: May 26 – July 24 (~ 8 weeks)

Date of examination: July 25

Results received: August 14 (~ 3 weeks)

Score: 243

Review course
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

Supplemental books
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
Picmonic (www.picmonic.com)
Goljan audio

Question bank
USMLE World
USMLE-Rx

Practice examination
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 studies. 

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 15.

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 anxiety. 

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 bed.

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 examination.

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)

http://www.nrmp.org/just-published-nrmpecfmg-charting-outcomes-match-international-medical-graduates/