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Student's Experience For Step 1

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This is an experience written by scottish student who took step 1
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 pathophysiologyical 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.

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.....
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Thanks dr mahdi, it is good informtion,
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Another IMG Student's Experience With Step 1
I am an IMG graduated in 1995. I am working full time in a research position. I started studying for the USMLE step 1 exam in February 2007. I used to study after work everyday for about 4-5 hours and about 10 hours during the weekend. My study material was:

Kaplan Videos
Kaplan Notes + Q Book
Goljan Audio & notes (Notes I could read only 50%)- Goljan a must
Neuro Anatomy-HY
UW (finished 2000 questions)
FA (65%)

Since I had serous problem managing my time I used my commuting time (1 hour per day) to and from work to hear Goljan using a MP 3 player.

When I took the exam my UW score (first time most in the timing mode) was 54%
NBME 2 4 days before the exam 410= 195

This was a mistake as I thought first to do the NBME so close to the exam. I was worried first but recovered within a day and fully concentrated next 3 days on my weak points.

I took the exam on October 30th and score reported after 3 weeks

Step1 Score 202(83).

I kept very calm and concentrated through out the exam, as I knew this would one way that I could score more than another person. I was exhausted after 5 blocks but kept my concentration as much as possible. First 4 blocks were OK and I felt I could pass but folowing that everything became very tough.

Questions were very nicely done and mostly clinically oriented. There were few (10) which was straight Q&A. I found points straight from Golan and UW. Questions were different from UW as Q’s were trickier and clinical oriented but UW preparation was extremely helpful.

I also did USMLE CS in June in Atlanta during the same time and passed. I used UW 100% and preparation was only 2 weeks. I timed and did all the cases. My patients were my wife and my little daughter.

During my preparation all I had was the determination to do well and pass the exam. Since I have some USA experience (Fellowship) and experience in 3 different countries in my field (Clinical Pathology) I never aimed 99 but I had to balance by understanding my own position balancing the work, study and the family. The strength behind was my little daughter, my wife and my parents.

I also want to thank my Indian friend who initially gave all the points what I have to do for preparation. If not for her I would have not done this easy. Than my two study partners (good friends) from my own country who helped in CS and other times where I was down during my preparation and all my friend s at work.

During my preparation all I had was the determination to do well and pass the exam. Since I have some USA experience (Fellowship) and experience in 3 different countries in my field (Clinical Pathology) I never aimed 99 but I had to balance by understanding my own position balancing the work, study and the family. The strength behind was my little daughter, my wife and my parents

Last but very important thing is that you should have a clear goal and you have to believe in your self. With all the difficulty I managed to do this (financial, work, family). I hope this information would be helpful to some one who is in the process of doing USMLE. I will write in Step 2 forum once I finish that exam.
Thank you.

Another IMG Student's Experience With Step 1
Before I begin, let me say that I feel like I have either barely passed... and if I did fail I don't see it being lower than 183. I can see myself between 183 and 190, and if I had to make a pinpoint guess - I would say I scored 188!

I knew about half of the questions for sure, everything else was between educated guesses or not knowing what the heck they were talking about at all.

I arrived two hours early to the center, and since it was indoors and a multi-story building, I was able to go inside before the center opened and sit there and study a bit to get the juices in my brain flowing. They tried to offer me locker #13 (and mind you, its halloween!). I jokingly requested a different locker saying that its bad luck especially on this day, and they gave me 14. I had no problems at the testing center but one thing I must mention is that it was freezing cold with the AC! I wore a jacket and I was still cold. I had sandals on though and my freet were so numb from the cold air that I had to sit "indian-style" cross-legged on my chair to keep warm while answering questions.

They provide you a few sheets to do scratch work on in case you need them during the exam. I actually used one of the sheets to write out 7 rows (one for each block), and keep a tally of how many questions I knew 100% for sure. I only marked on the sheet if I was completely positive its the right answer, otherwise I didn't. At the end, I counted up how many questions I knew for sure overall. If I end up passing, maybe you guys will want to use this same idea just to see how you compared to me and that way you can tell if you passed that way... so you won't have to wait 3 weeks crossing your fingers if you passed or not.

The exam was very well divided in all subjects. It seems like the question stems had most of the pathology, but the answers were of anatomy, physiology, molecular, behavioral, etc. The only time I got a direct pathology answer choice was if it was some "not-so-popular" diseases. I knew First Aid very well, but everytime I was reading a question.. I knew that the topic is in First Aid but the answer they wanted could not be found in First Aid. I feel like they did this on purpose because they know many people study that book as a shortcut. Its a great book as a checklist or outline tool, but it only scratches the surface and doesn't always get you the right answer. I would say only 25% of the answers can be found in First Aid, but 70% of the topics can be found in there. So be careful when you study it and not to use it as your top source, but rather as a backup.

My study sources were: Kaplan Lecture Notes, First Aid, USMLERX, and Kaplan Qbank. I did try out USMLE World for a bit but I didn't find it as helpful to me.. but I know its the #1 choice for many of the other students out there.. everyone is different. I think USMLE World is great for preparing you for complex questions, but what I really wanted was a question bank that tests out topic more likely to show on my exam.. I don't have trouble breaking questions down, I just want the knowledge to answer them. USMLE World had a lot of fluff points that I didn't expect to see in the exam, and I didn't. USMLERX was a bit too easy because half the questions are straightforward, but I think my biggest help was the OTHER HALF of the USMLERX questions. About 1400 of them are medium to hard difficulty, and those were right on the nail for the actual exam. I had many rephrased questions matching USMLERX. And I have to also say that USMLERX doesn't simply re-itterate the First Aid in those other 1400 questions, it does go beyond the book for those ones. That is just my feeling from my own exam.. By the way, I also did the NBME exams, but not to test myself, but to rather analyze all the concepts so I knew them a sufficient amount of time prior to the real exam.. that way I can think in their ways.

Block 1: This was a tough block for me. After I completed this block I felt like I am going to fail the exam. I tallied up that I knew 20/50 questions for sure, the rest were educated guesses.

Block 2: This really changed my perception of the exam, as this was easiest block. I knew about 32 questions for sure in this section, so overall at this point I knew a little more than half of the questions I answered for sure.

Block 3, 4, 5: These blocks were all very similar in difficulty for me. I knew about 26 to 27 questions for sure in each of these sections. I felt like if I knew a little more than half on avarage in this exam that I should pass (175/350 for sure, then educated guesses on top of that should put me over the 185 mark)?

Block 6: This block crushed my confidence completely. I was dying in this block. Out of the first 18 questions I only knew 3 of them for sure. Eventually by the end of the block I knew 18/50 for sure.

Block 7: This block was tough too, but it was not as bad as Blocks 1 and 6. Eventually, I ended up knowing 23/50 questions for sure.

Overall: The exam was well rounded in every subject and system, and basically there are no shortcuts to study for this exam. I feel Kaplan's Lecture Books are the way to go with this exam, First Aid only as a review resource since its incomplete based on the new question pool added after this summer, and any question bank of your choice as long as you are confident of your knowledge from the Kaplan material. I knew 172/350 questions for sure, which is an avarage of about 24.5 per block, and just short of knowing half the questions confidently.

When I get my score I will gladly post it here so you can see what all these numbers will mean for you when you go and take your exam, and you can use them as a comparison. I bought the 2007 Kaplan Lecture Videos to study for this exam, so if anyone needs them I would like to sell them off to get my money back for what I paid (200). I also have the Kaplan Self-Assessment 10 diagnostic exams that are only available in the actual $5000 Kaplan course (I didn't take it, but my roommate did and shared with me). You can e-mail me at if you have any questions about the exam itself or are interested in this stuff I used for my own exam.

Good luck, and take care guys! I hope my exam experience was helpful.

Inalilah waina ilaihi rajicuun!i am teriffied now tht ive read their step 1 exp.its hard!how in gods name am i gona do tht?its med school all over again.not only do they expect u to remember everythin bt they twist the questions so the que are disguised as wolf in sheeps clothin.wallahi am discouraged.its not worth it.after studyin so long,payin so much muni,ure in risk of failing n goin thru tht nightmare again.its just not worth it


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