Thursday, July 17, 2014

How to Score 270+ on the USMLE Step 1

I came across the following post while reading through Step 1 experiences over at SDN.  By now you may have noticed that the content of my blog has switched to focusing on Step 1 and the first two years of medical school.  Most of the stuff I am posting here is actually so I don't forget it.  I want to come back and look at this as I start to study more aggressively for the steps.  I know that most people will study for it during the six weeks after their second year, but after you read the following I think you may come to the same conclusion as I.  Waiting until then, while you can be successful, will not yield an optimal score.


The following is a write-up posted by "Golf med student" over at SDN



First of all I want to say that my initial goal was 240. It seemed like the magical number that would at least get you in the door at most specialties. The point I want to make is this, get a score in mind that you want to achieve and work towards it. You need goals in order to push you further. If you surpass your goals in your studies then continue to increase your goal so that you can achieve the highest score you possibly can. Even though 240 was my goal internally and a score that I would be happy with, I was really pushing for 250. When it comes to standardized exams I have learned in my experience that I fail in achieving my goals more often than not. Maybe that is just because I set too high of goals for myself to begin with but that’s another story. The idea here is that shoot for the moon because if you fail at least you’ll fall among the stars. But when I started getting 250s on my practice exams I tried to push for a 260. Don’t sell yourself short! Believe in yourself!

My study prep really was based on a few guiding principles that I used. I also experimented a bit with different methods but I will give below the schedule that I would follow knowing what I know now starting in the fall. This method is really just my own but I think it gives you the best chance to get the highest score you possibly can.

The first principle I based my schedule on was the idea that we can only remember about 75% of what we see/read. Since we are not in clinic yet (US medical students) it can be hard to remember everything without actually having experienced it. This concept led me to use multiple resources that used different types of learning modalities. The idea is that you read something, listen or watch something, and then also answer questions on the topic.

The next principle kind of ties into the last one in a sense because I knew I would forget things, I decided that I was also in need of spaced repetition. I did this by narrowing down resources as the year went along. I’ll explain this a bit later but all I really did was start with subject books focused on anatomy, biochemistry, etc. before starting a comprehensive review source like First Aid. It made knowing the information in first aid seem like it wasn’t too much and just the bare essentials. I added in firecracker also here but I used it in a way that I don’t think many have tried. I’ll detail it out more below.

The last and probably most important principle I used was that it takes 10,000 of something to become proficient. In this case it is 10,000 questions. They don’t necessarily all have to be unique but you want to try to go through the thinking process of eliminating all the answers for a certain reason. For instance maybe the first time I see a question I only know what the correct answer is but all the other choices don’t make sense. The second time I see the question I want to try to eliminate all the others based on the information in the stem in order to lead me to the correct answer choice. This makes the question just as valuable the second time around.

Now on to the schedule!

If I were to do it again I would personally start my STEP prep in August. I would spend the fall getting a broad understanding of all the topics I covered in first year and then onto in second year including the things we are going to cover in the upcoming spring semester. By reading all of these books you may not remember everything in the book but you become familiar with the book to the point that you can use it for quick reference during dedicated studying. Then if you have to reread up on lets say the difference between conus medullaris and cauda equina syndrome you have a general sense of where it is in the book and it only takes a few moments to jog your memory rather than having to learn it for the first time. At my medical school the topics we were on a block schedule so during first year we covered anatomy, biochemistry and cell biology, physiology, microbiology and immunology. In the fall of second year we covered neuroanatomy and pathology principles including hematology/oncology pathology and musculoskeletal pathology. During the spring we covered behavioral science, cardiology pathology, pulmonary pathology, renal pathology, gastrointestinal pathology, endocrine pathology, reproductive pathology, and skin pathology.

Anatomy – HY Anatomy – I read this book during the fall semester, I don’t necessarily feel that it aided me in any questions but it was a good review of anatomy from the previous year and I think helps in creating a solid foundation to build on that you need in this area. As many have said before they have many radiographic images that are helpful. I hardly ever missed any anatomy questions when I finally got to qbanks so maybe it could be attributed to this book or just learning it really well during the block.

Embryology – HY Embryology – This is really a great book! I didn’t feel like I really learned my embryology well during our anatomy block but after reading this book I felt much more comfortable answering the questions that would come up. I think if you feel weak in this area, I would definitely pick this up because it’s a quick read and prepares you well to answer questions on the topic.

Biochemistry – Lippincott Biochemistry – I also read this book during the fall semester. It was extremely useful! I know that many say it is too long and is not worth it. I graduated with my undergraduate degree in biochemistry and I felt this was so much better organized than RR Biochemistry. The images and diagrams were easy to navigate and I referred to it many times during my dedicated step study

Cell Biology – HY Cell and Molecular Biology – I was also a cell and molecular biology minor so this book was something I was really familiar with. It was a good refresher and a quick read so not too much of a commitment.

Genetics – HY Genetics – This was also a very quick read and had good coverage of the topics that were covered in questions. Not a big commitment in terms of reading but I felt worth the little amount of effort.

Physiology – BRS physiology – The gold standard when it comes to physiology. You can’t really go wrong with this book. I re-read it but felt it was lacking in some areas specifically cardiac physiology and respiratory physiology. Maybe that’s just because I used big Costanza and West respiratory physiology. I went back and added in some info that I felt was important to the book but they ended up not being very important in the end. Just stick to this book for physiology and you’ll be good to go as far as the basics.

Microbiology and Immunology – Review of Medical Microbiology and Immunology (Levinson) – I actually read Medical Microbiology Made Ridiculously Simple (MMRS) but I felt this book was much better and didn’t have all the fluff that was in MMRS. Maybe I didn’t get a lot out of MMRS because I also used picmonic (I’ll talk about picmonic soon!), which has a similar kind of learning style but much better organized. The parasite review was just so much better in Levinson and that was a weakness I felt that I had so that could be it as well. The immunology section was also short and to the point. I have a pretty strong background in immunology so maybe it wouldn’t be ideal for those that feel a weakness.

Neuroanatomy – HY Neuroanatomy – This is another book that is great! Has everything in it that you need to know for STEP and more. I would highly recommend it! Plus it is short and does not take long to read.

Behavioral Science – BRS Behavioral Science – I know that the last edition of First Aid recommended HY Behavioral Science but it is just not enough. I read the HY and constantly had to go back and read the BRS. I wish I would have just sucked it up and read the BRS to begin with like I planned. My lowest test subject on my actual exam ended up being this so I ended up paying for not reading this book. In addition to reading this book I would also recommend watching the Kaplan videos on Behavioral Science. The guy that does them is absolutely amazing and simplifies the subject enough to help answer a lot of questions.

Pharmacology – Katzung & Trevor’s Pharmacology Board Review and Examination – There are two of these books that seem similar online but one is the entire text and the other is a review. Pick the review book! It was short and had basic information that allowed me to create a framework for each of the actual drugs. Questions at the end of each chapter were nice as well to make sure you picked out important information. I also watched the Kaplan videos for this topic because Raymond is amazing and helps a lot with understanding the pharmacology.

Pathology – Pathoma/RR Pathology – Your test no matter what subject it is heavy in or balanced will be mainly pathology. It makes sense then to read a couple of books on the topic. I started with Pathoma and watched all the videos while reading the text. I then read RR. I did not listen to the audio and I’ll tell you why. Those tapes are now almost 15 years old! Information has changed and he has everything that he talks about in the book. Read the book and you’ll be better prepared. It brings everything together at the end because he integrates the physiology and biochemistry with the pathology.

So those are the books I would read during the fall to prepare you for a spring full of questions and First Aid. The reason for reading is mainly a leveling process. Each school is slightly different in the curriculum they stress so all of our education is slightly different. I feel these books are basic enough where it is material that everyone should have at least heard of after the first two years of medical school. I added in videos to the topics of behavioral science, pharmacology, and pathology because I think they are the most tested. I know microbiology is also heavily tested but it is just memorization in the end and we also had very good lectures in the subject at my school. I also think here is a good time to talk about picmonic. If you haven’t heard of it check it out. It is definitely not for everyone but it helped me immensely to have a starting point for memorizing the topics they covered. I think that for me personally it worked best for biochemistry and microbiology but that was most likely due to the fact that it hasn’t been around very long and those were really the only cards I got to see a lot. I would focus on doing whatever cards you are currently learning in class. If you are in microbiology learning about gram-positive bacteria do those cards. Listen to the audio for each card once at the very beginning of the week or two weeks you are studying that topic and then during the week look at them right before you go to sleep. You’ll have some crazy dreams but it makes them stick in your mind when you are under pressure. They have added many more cards now and I tried to use them but I had already memorized the topic before seeing them so they weren’t as helpful. They correlate directly with what is in First Aid so you know it is essential information that will show up on the exam. The amount of questions I got right in biochemistry and microbiology were mainly due to this resource so I would highly recommend it.

The springtime is for learning how to answer questions and getting First Aid filled out to use as the ultimate resource in your final study period. After all this reading you might think that you would be well prepared to answer questions but it really doesn’t happen that way. It takes time to understand how concepts are going to be asked and what the important information is. Don’t worry! I had the same experience and it is just a process of playing the game.

First qbank – USMLE Rx – Start with this qbank! There are a little over 2700 questions so try to have it done by the end of February. The questions all have links to the page where it is in First Aid. This helps you get acquainted with FA and where everything is. I cannot tell you even after doing this how many times I would write something somewhere and then find it printed somewhere else. Learn where things are in FA and you’ll save yourself time from writing down redundant information. Go through the qbank by the way it is divided in First Aid. For instance I started with Behavioral Science. I first read the section in FA and then would answer the questions associated with that topic. This will be your first read through FA and will also aid in knowing where everything is. For pharmacology and pathology, I answered the questions by organ system instead. Reading FA and then answering questions over the topic helps to cement the information in your mind. When putting information from the question into FA I only wrote down the core objective at the end of each question. I did the questions in tutor mode because immediate feedback is so important. I only used timed mode when I was in my final prep period. I will explain this in more detail later though.

Second qbank – Uworld – The reason for doing this second is that you can reset this bank and you want to do this twice because it really is the best prep for the detail on the exam. This will be your first pass through the bank. It is harder than Rx so don’t worry if you see your scores drop. (Also unlike Rx when you click on an answer it doesn’t let you change it and shows you the explanation.) Do it on tutor mode and write in all the educational objectives at the end of the explanations into your First Aid. Don’t do this by specific topic like you did with the previous one. Select all subjects and organ systems so you start to get a feel for what it’s like to have mixed exams. You’ll want to try to complete this by the end of March.

Third qbank – Kaplan – This qbank tests a lot of minutiae but I got several questions on my exam correct because of the questions I saw here. This was also my only place to see menkes disease (it is definitely in FA in the biochem section) so you know it has been on the real thing before. The bank also does a good job of giving you plenty of practice with the arrow questions for physiology. For example the patient comes in with this disease, happens to x, y, z. It is also the best for behavioral science and laboratory medicine. First do the diagnostic exam to see where you are after two qbanks. Do it in tutor mode with all subjects and organ systems selected. Write down the key concept at the end of the explanation in your First Aid. You’ll want to try to complete this by the end of April

During uworld and Kaplan banks read First Aid for a second time. Take the time to find information that you missed in your first pass! You’ll start to be surprised by how much you missed and how much information is actually in First Aid.

Dedicated STEP study time:
So for this it really is up to the individual but this is how I did it and I don’t think many other people did it this way. I scheduled 5 weeks of dedicated study time. It was a little more than the month that I thought I would need but it gave me the ability to take one day off a week and also celebrate my MBA graduation and my fiancée’s birthday. During the time I thought that it was too much but now that I have my score back I am happy with my decision on taking 5 weeks. So here is what I would recommend based on that 5 week schedule. If you choose to do something other than this it is fine, by this time you kind of know where you are and where you want to go. I don’t think any of the DIT or Falcon review courses are worth it at this point either if you have followed this schedule from August. Those are designed to help people pass STEP who haven’t been studying very hard during second year.

Uworld – Second pass. This time you want to set it up for timed and select all subjects and organ systems. Review the entire test after you complete it. This helps get you prepared for the real thing by getting your timing down and working on your thinking process. You stop worrying about whether or not you got a question right and just learn to try your best and move on. You know all of the answers to this qbank so any question you miss means there is a fault in the process you are using to answer the question. Find it and work on it. Sometimes it is that you are thinking too much and other times its because you aren’t paying attention. Find the right balance that allows you to function at your optimum level. Try once again to finish this qbank in 4 weeks. It should be easier this time since you aren’t writing everything down. Don’t worry if you aren’t getting every question right! I know of people who had a second pass percentage rate around the 80% mark and still did well. The key is to figure out why you missed those questions the second time around! I did my questions every morning.

Firecracker – This is what I did in the afternoons. I know this is not how most people use this program but based on my experience with it during first year this is what I did because I knew it would work for me. I completely reset my account so that I did not have any topics flagged. Prior to this I may have flagged about 40% of the topics with none from the organ systems section. I then did approximately 50 topics a day so that I could finish flag everything within four weeks. It is definitely a lot towards the end but this was my way of reviewing as much as I could with spaced repetition so I wouldn’t forget what I learned in the first week by the time I took the exam at the end of the fifth week. I knew after the Kaplan diagnostic exam where my weaknesses were so I did those sections first to give myself the opportunity to see those cards the most. This may not be for everyone but it definitely helped me with my microbiology, dermatology, reproductive, and renal questions that were a relative weakness going in to dedicated study time.

CBSSAs- DO THEM ALL! All of the ones online are around $50 and there are 6 so it is an investment but I saw several questions and pictures from these on my actual exam. In my mind that in itself makes it worth it. Try to do one once a week starting with the first week so you can have them done before your exam. Don’t stress too much about the scores you get. Most people I have talked to tend to get a score a few points above their highest CBSSA. Also this is a great chance to meet with a study group. Throughout my second year, I met with a group of like-minded students that were dedicated to STEP studying at an early date. We would meet once a week and answer 10-15 questions over an hour from a question book and just discusses how we each arrived at the answer. We continued this process by meeting up on Sundays to discuss the questions we missed on the CBSSA. You don’t get the correct answer for the questions you missed if you choose extended feedback (you should choose this option, its $10 more but you only take STEP 1 once so its worth it!). You just get the question and detailed statistics on the different subjects and organ systems. You can use this to tailor your studying for the next week if you aren’t doing the Firecracker method.

Last week before the exam: Do the two practice exams on Uworld, they are pretty good but tend to overestimate your actual score. Try to focus once again on limiting the number of mistakes you make in your thinking process. At this point you know or have seen it all and it is just about minimizing stupid mistakes. By that I mean mixing up biostatistics formulas or other simple questions that are supposed to be the easy ones. You can’t get the highest score you’re capable of without learning to do this. For example, on one of these practice exams was a classic “EXCEPT” question. STEP isn’t allowed to ask these questions anymore but they have technical way of doing it. They give you a vignette and you have no clue what it is. You look at the answer choices and see that you know four of them but the other one is a mystery and you’ve never heard of it. The point of the question is to know those more common four and exclude them based on the information in the vignette so you can choose that one you’ve never heard of before. If you are able to do that with good reasons for excluding each wrong answer choice you are able to think like the question writers and that is the name of the game! The other thing to do during this week is read through First Aid for the last time. You have put a bunch of notes in there from all of the questions you’ve answered. Use a fine tooth comb and find all the little details that you don’t remember. Don’t worry if you are finding there is too much to First Aid and you can’t possibly know everything in there. Just by doing this you’ll get several questions correct that you wouldn’t have on your exam. I know because that’s what happened for me (do you remember what the dihydrorhodamine test is used to diagnose? Chronic Granulomatous Disease and it is in First Aid!) A few days before your exam do the free 138 questions given by the NBME. They are good questions and a couple showed up on my exam.

Take the day off before your exam! You need to be in top shape for tomorrow and not tired. Watch a movie, eat well, and get some good rest! Do whatever you have to do to relax.

Wake up early on the exam day and get to your testing center early (like 30 minutes early). You don’t want to add stress to the actual day. I ate some protein (eggs and bacon) for breakfast. All I am saying is to eat something that will last and keep your energy up for the exam. I also did 10 random questions and read the rapid review section at the end of First Aid before I left. This helped me to get in the question-answering mood and was a good overall review of commonly tested items. Take plenty of food and drinks. Try to mix it up so you can eat whatever you want (I took some sandwiches, crackers, and candy bars… filling, salty, sweet). I also took some 5 hour energy shots with me. I drank one before I went in and then another in the afternoon. I know I’m blatantly copying their ad but I don’t feel the crash with it as I do with coffee or cokes so that is why I choose it over them. It kept my energy up and felt great the whole day. Try to stay calm, cool, and collected. Don’t over think and try to minimize your mistakes. Manage your break time. They give you about 45 minutes of break time plus whatever time from skipping through the tutorial. I did a little of the tutorial because the auscultation on the exam allows you to move the stethoscope around and change from diaphragm to bell unlike any of the other testing services. I would get done answering all the questions around 20-15 minutes left in the block mark and then review all of my answers for another 10 minutes so I would have about 5-10 minutes after every block. I took a thirty-minute break for lunch after the fourth block. I took slightly longer breaks in the afternoon because I knew that I would be tired from answering all those questions earlier in the day. I ended up using almost all of my time.


Congratulations! You’ve just completed taking one of the most stressful exams of your life! Go enjoy life and catch up with all those friends you’ve ignored for the past month while you’ve been studying! It usually takes about 3 weeks to get your results which will be posted to the same website where you registered for STEP 1. They only release scores on Wednesday and will send an email saying your scores will be uploaded later that day. If you take your exam during May/June they may have a single date for everyone for a certain heavy testing period. For example, when I took the exam all the scores from May through June 19th were uploaded on July 9th. They usually post this information to their website if they are going to do something similar during the time you take it.