Step 1 Study Experience

Discussion in 'USMLE Forum' started by Scottish Chap, Jul 28, 2007.

  1. Scottish Chap

    Scottish Chap Super Moderator

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    Many people have been asking how I prepared for Step 1. Sorry for the delay in responding. The most important thing I want to say is that you should have a target score in mind. For me, my target was to get above the national mean. Although I’m British and I was educated in the U.K. for most of my life, I attend an American medical school so I’m very familiar with what’s required on either side of the pond.

    Disclaimer: this is only my opinion. I have no inside secrets and I am most definitely not going to reconstruct Step 1 questions from memory. With respect for the test writers, please don’t ask me to do this.

    For Step 1, the best advice I can give medical students is to work hard while you are in medical school. Step 1 does not ask ‘what’, it asks ‘why’. It is not really a test that rewards the best of memorisers (and I’m not one of them). It is an exam that requires understanding. It covers a LOT of information, but it’s not impossible to pass if you prepare diligently and take enough time to relax. You are expected to know the pathophysiological mechanisms behind all of the major diseases, and often they are merely implied in the question stem. There are few ‘knee-jerk’ prompts in the questions stem, and often you will have nothing more than symptoms, laboratory data, and a peripheral blood smear to pick up on a disease like hereditary elliptocytosis (something similar turned up on my exam).

    Keep in mind that what worked for me might not work for you. I studied for four weeks, and I studied around eight hours per day. Some days, I was less productive. Overall, I was relaxed and I did not kill myself. I consider myself to be an average medical student. These are the resources that I found to be most useful, in my humble opinion:

    1. First Aid for Step 1. If you know this book cold, you’ll be fine. It contains all of the high-yield information on Step 1. Beware: it is VERY abbreviated and, by itself, it is useless and nonsensical. My strategy was to make my own extended notes in the margin while I was taking some of the heavily-tested subjects on Step 1 in medical school (pathology, pharmacology, immunology etc.). By the time I came to prepare for Step 1, FA was quite complete, and I just referred to it when I had time, and I spent the last three days memorising as much minutia as I possibly could before Step 1.

    2. Robbins Review of Pathology Question book. These questions are VERY hard, and quite involved. I would say that they are a little harder than what Step 1 expects of you, but the question length and the second- and third-order thinking needed to do well on Step 1 is pretty similar. Pathology and pathophysiology are without doubt the most heavily-tested entities on Step 1. This is high-yield.

    3. BRS pathology. An excellent book that I used alongside my medical school pathology course. The questions are easier than what you’ll see on Step 1, but it has everything there and it’s more complete than First Aid.

    4. BRS physiology. This is an excellent summary of all of the major mechanisms that turn up on Step 1. Step 1 physiology questions are often integrated with pathology, and my own experience was a whirlwind of “up/down” arrow questions for endocrinology and acid-base balance. I would know those cold. In addition, Step 1 will expect you to interpret all of the pulmonary and cardiovascular graphs rapidly (volume-pressure loops, wigger diagram, murmurs, FEV1 curves, flow in the circulation etc,) so this is worth knowing well. You also need to know all of the major calculations in cardiovascular, renal, and pulmonary physiology, and pharmacokinetics for pharmacology.

    5. Medical Microbiology Made Ridiculously Simple. I read this book slowly, and found it to be high-yield. My own Step 1 exam required one to know all of the lab tests that you’d use for common bacteria and viruses as well as which viruses are single-stranded, naked etc. Often, this is implied in the question stem – the symptoms of a virus are given, and you will be expected to identify the virus in the options by knowing if it’s made of DNA or RNA, single-stranded, naked or enveloped etc. Parasites and fungi are lower yield, but fair game. Often microbiology is integrated with pharmacology: they might show you a picture of neisseria gonorrhea, describe some symptoms, and expect you to pick out that ceftriaxone is the best outpatient drug of choice in the first instance.

    6. Kaplan Pharmacology Lecture Notes. I can’t say enough about this book. It gives you exactly what you need to know for Step 1. It is also high yield. You are held accountable for all of the major drugs and side effects, and the post-receptor signal transduction pathways (I had around 10 of those questions on my own exam).

    7. Kaplan biochemistry and Genetics Lecture Notes. This is detailed, but it is excellent. You MUST know all of the major enzymes and rate-limiting steps involved in inborn errors of metabolism. You MUST know all of the rate-determining steps in glycolysis, the TCA cycle, the electron transport system (including all of the shuttles), fatty acid biosynthesis, beta oxidation, the pentose phosphate shunt pathway, the Cori Cycle, the Urea Cycle etc. I had several vitamin questions that required you to know which biochemical enzymes use them, and what the symptoms would be. There were several molecular questions on my test, but I honestly felt that any reasonably-bright medical student would be able to work them out right there – PCR, interpreting paternity DNA digests, Southern blots, Westerns, and knowing the nuts and bolts of immunoassays, fluorescent immunostains, and FACS analysis. Hardy-Weinberg calculations are fair game, and you must know all of the major diseases and their mode of inheritance (autosomal, x-linked, mitochondrial, dominant, recessive, and how this changed with penetrance and mosaicism etc.)

    8: Kaplan Anatomy and Embryology Lecture Notes. Most of the anatomy is integrated with pathology. They might describe a knife fight and the presentation of a patient to the ER and, from the description of the laceration, you'll need to know which lobe of which lung or which chamber of the heart is punctured, and at which vertebral level this can be found. I had a ton of MRIs and CTs (especially of the head) on my exam, and I found the neuro section of this book to be excellent. You MUST know all of the major nuclei at every level of the brain stem and spinal cord, and know the major lesions and symptoms - including the odd ones like ALS, MS, syringomyelia etc. You also need to know all of the major nerve tracts in the spinal cord and all of the cranial nerve signs cold. I make no bones about this. It's important and it's very high yield. The First Aid book is totally useless for anatomy, in my opinion. Brachial plexus is very high yield. I had three questions on my exam that required you to know the plexus by heart and identify a nerve root from a diagram, and localise motor and sensory lesions from symptoms. For embryology, the pharyngeal pouches are high yield - as are gut and cardiac malformations. I hated anatomy and embryology in medical school because I loathe memorisation for the sake memorisation, though I found that simply doing questions was enough to make me presentable - other than for neuro which, again, is very high yield.

    9. Kaplan Q bank. I got through around 80% of this, but honestly felt that the questions were too esoteric and not reflective of what’s on Step 1 at all. This is a little outdated. However, the long questions and question choices (anything from A-to-D to A-to-K! That’s right) are fair game on Step 1. That was a shocker for me. I expected all of the Step 1 questions to be A-to-E. Several were, but anything is possible. Kaplan’s explanations are a little outdated, but it will get you to where you need to be. DO NOT WORRY ABOUT YOUR SCORE. FOCUS ON LEARNING. I always did these questions in the mixed, timed, and unused mode.

    10. USMLEWORLD. I felt that the second- and third-order questions on here were very similar to the thought process needed to do well on Step 1. There are many subtleties in the question stem that you must pick up on to get the right answer. In addition, the explanations here are superior to Kaplan, in my opinion. However, the question stems are FAR too short and do not reflect Step 1 at all. This led me into a false sense of security. There were also a lot of annoying typos in there, making me question the QC of this company. The computer interface on this question bank is identical to Step 1 and this may get USMLEWORLD in trouble sooner or later; I did not think the latter feature conferred a significant advantage. I got through around 90% of USMLEWORLD, and I was pleased with my purchase. DO NOT WORRY ABOUT YOUR SCORE. FOCUS ON LEARNING. I always did these questions in the mixed, timed, and unused mode. In the last 2 weeks, I did around 150 questions per day in 50 question blocks, and went over the answers. I wrote down anything that surprised me. In my opinion, making detailed paper notes for everything is not a valuable use of time. Towards the ends, I did around 300 questions per day to build up my stamina for Step 1.

    I hope that helps. Good luck to whomever is reading this!
     
    #1 Scottish Chap, Jul 28, 2007
    Last edited: Feb 3, 2008
  2. Scottish Chap

    Scottish Chap Super Moderator

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    Some more info. on Step 1

    Step 1 is 350 questions long, administered in 50 question blocks. Once you start a block, you must continue that block. You are given eight hours to complete the exam and (if memory serves) only 45 minutes can be used as break time, and you can take that between blocks as you see fit; I did two blocks, took a five minute break, did this again, took lunch, then took 5-8 minutes after each remaining block. You basically have one hour for a 50-question block, and it is harder than one thinks to finish on time. The most time I had was 7 minutes after my first block. The least time I had was 2 seconds after block 3 (where I felt like I guessed on >50% of the questions). Rumour has I that Step 1 contains 50 “experimental” questions (new ones that are still being monitored), so your score is really out of 300. The NBME (the writers of the exam) are quite secretive and it’s not really known how they grade the exam, but it is ‘scaled’ so that a score of 215 ten years ago is equivalent to a score of 215 today.

    Passing Step 1 requires a three-digit score of 185 (a correspnding two-digit score of 75; THIS IS NOT A PERCENTILE OR % CORRECT). The mean is around 215, with an SD of around 20. Approximately 94% of U.S. allopathic (M.D.) medical students pass Step 1 on their first attempt. Approximately 67% of foreign medical students pass Step 1 on their first attempt. This is data is from last year. I know two students (stateside and foreign) that did not pass Step 1 on their first attempt - both are now board-certified physicians in the U.S.

    If you attend a medical school outside of the United States and you want to complete your post-graduate training in the U.S., I will emphasise that it’s important to perform well on Step 1 – at least at the national mean. For very competitive residency programmes (orthopaedic surgery, ophthalmology, ENT, plastic surgery etc.) or for not-so-competitive residency programmes at competitive institutions (internal medicine, paediatrics, family medicine at Johns Hopkins, Harvard, Yale, Stanford, Columbia, Mayo Clinic etc.) it’s very important that you obtain a high score on both Step 1 and Step 2 of the USMLE. Keep in mind there are always exceptions to the general rules above. There are currently more positions for medical graduates in the U.S. than there are applicants to fill them, so most people will match in something somewhere. Bottom line: do your best, and always treat people well along the way.

    Overall, I feel that Step 1 of the USMLE is a fair exam and it really did distribute questions pretty evenly throughout all of the medical school basic sciences (pathology, pathophysiology, pharmacology, physiology, cell biology and histology, anatomy and embryology, biochemistry, genetics, behavioural science and statistics, microbiology, immunology, basic physical diagnosis, ethics, nutrition, neuroscience). Most people leave Step 1 feeling like they only got around 40% of the questions correct. For most, there is undue anxiety. Keep in mind that your score is relative to other test-takers. If you found it hard, chances are that the person taking it the next day will also find it hard. There are multiple versions of the exam out there, and some test takers have reported seeing an emphasis on one subject area; for me, that would probably be neuroscience. Forget about the exam until your score arrives (usually in 4-6 weeks, stateside).

    You can purchase 'retired' Step 1 exams from the NBME website for around $45. They should be used ONLY as guidance regarding your strong and weak areas (you get a subject-based profile at the end, and not correct/incorrect answers). I took one of these exams half-way through my study schedule. My real Step 1 score was one point higher than this exam. Take that any way you wish.....
     
    #2 Scottish Chap, Jul 28, 2007
    Last edited: Aug 9, 2007
  3. *ACE

    *ACE New Member

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    Very detailed advice, thanks SC!

    Have a headache at the moment so I will have to come back for a re-read, but thanks and good luck with all your endeaveours.
     
  4. bussi

    bussi New Member

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    thanks&advice in my case

    sir,
    i justentered internship program ,from india.ineed your advice regarding my preaparation.
     
  5. egyptian skull

    egyptian skull New Member

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    thanks alot
     
  6. dratiffarid

    dratiffarid New Member

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    thx a lot!
     
  7. genser

    genser New Member

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    Wow, very detailed, thank you!
    If I may ask, who is the author of the book First Aid for Step 1?
    Thanks very much
     
  8. bussi

    bussi New Member

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    thanks
     
  9. Tangliss

    Tangliss Super Duper Moderator

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    Fab advice!!!
     
  10. asklepios

    asklepios New Member

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    When to sit Step 1?

    Thanks for the info on here, scottish chap! I find your method corresponds to what I've read on studentdoctor.net, so shall mimic such study techniques and resources.

    I have a question for UK-trained folks, or those who know someone who trained here and then went to the US. At what point in your training did you find the USMLE Step 1 best to tackle? I'm just finishing my pre-clinical studies and thinking of going back to the US for residency. I've looked at some practice material for Step 1 and it looks way more detailed and involved than what I've learned thus far. I know that US students take the exam after the first 2 years.

    I was thinking it might be good to wait until I have more clinical experience, like after my 4th year, or maybe after my 5th year exams (since I'll have to revise all of the years anyhow) and then come back to learn the more detailed pathophysiology and pharmacology, when I can tie them to concrete cases I've actually seen. What do you all think? What worked best for you? I've only talked to one person, an F2 doc who said she wishes she'd taken the exam right after learning all this stuff the first time.

    Thanks!
     
  11. dr.argus

    dr.argus New Member

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  12. jtlc2345

    jtlc2345 New Member

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    Having just done Step 1 this summer, I think that you should definately wait until you have done at least some clinical medicine. There is no way that I would have known a lot of the questions (for example side effects of medication) without having seen them demonstrated in practice - although I still wish I'd done more revision!

    Jonathan
     
  13. MedicMark?

    MedicMark? New Member

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    I'd second this. I took step one a few weeks ago, so I don't yet know the result, but I would say that having a year of clinical behind me helped with lots of questions. 99% of the Qs are 2 step reasoning where they start with a barn door obvious scenario (eg "woman comes into A&E with scalp tenderness and jaw claudication") From this you are meant to get temporal arteritis without even thinking about it. Then the actual question will be something unpleasant like "what would you see if you viewed her blood film?" and you would need to know that she would have a raised ESR and therefore you;d see rouleaux formation blah blah blah

    So the first of the 2 step reasoning process, I think, is easier if you've had a year or two of clinical medicine where those classic presentations are discussed and/or seen, rather than just memorised.

    The downside of waiting until the clinical years is that you are still buried in the basic clinical sciences and your grades for clinical finals or other exams may suffer as a result. There's not an ideal solution but I suspect I would have found step 1 harder if I had done it before clinical med
     
  14. mark5

    mark5 New Member

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    Hi,

    This is Mark. I'm happy to join this forum. I run a resourceful website for USMLE and ABSITE preparations at www.clinicalreview.com.And Im looking forward to be an active member in this forum.

    Thanks,
    Mark
     
  15. mihir

    mihir New Member

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    has anyone taken step 1 recently? how often is it offered in the UK? weekly? monthly?

    thanks
     
  16. jtlc2345

    jtlc2345 New Member

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    You just take it on a computer so is offered on a year round basis - a bit like driving theory test.

    Jonathan
     

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