How to Crush the USMLE Step 1

Posted on May 14, 2011


The sympathetic nervous system mediates the classic “fight or flight” response – pupils dilate, the heart races, sphincters contract, and hair stands on end.  “If you have a cat at home, put his favorite food in a dish. Then just before he starts to eat, snatch the dish away. Before he scratches you, look at his pupils – that’s a [sympathetic nervous system] response,” a mentor once told me.  Fortunately, if you’re not a cat person, you can also elicit this response by mentioning the USMLE Step 1 to any second year medical student in America.

Having just experienced this exam myself, I can attest to its grueling nature – a 7+ hour exam on all one has learned in the first two years of medical school (with some topics reaching back to undergraduate education).  However, the test is also a rite of passage, and I can’t say I disagree with being subjected to it – studying for this exam forces you to stand back and appreciate the breadth of medicine (though the exam is far from exhaustive) and also to make associations between disparate topics.

Before you read further, full disclosure:  my results have not yet been mailed to me†.  I am writing this article because I took the test rather early and have friends who can still benefit from my advice, which I humbly present to you below.  If you are interested in the results of my prep, skip to the bottom before continuing – the rest of this article will be dedicated to strategies and ‘rules’ to help you succeed.

You have to start by outlining your goals – if you don’t have goals, you can’t have a plan, and if you don’t have a plan, you’ve forfeited, period.  Given the sheer volume of information this test asks you to regurgitate (and sometimes apply), if you don’t have a plan, you’ll be eaten alive.  Additionally, you will wind up with very different study plans if you want to score a 220 vs. a 260.  For example, if I wanted to score a 220, I could have completely ignored Embryology and Biochemistry, and I would have created a less intense schedule for myself (which would have made me very happy).  The rules below are personal advice from me, if you’re aiming for a competitive score:

Rule #1:  Whatever plan you make is the right plan

The most important thing to do is have a plan.  Don’t get bogged down in what’s most effective – hopefully after 2 years of medical school, you know that this is a scenario that has no one best answer.  When you settle on a thought-out plan, congratulate yourself, and stick to it, with few exceptions.  If something is truly not working and you have 3 weeks left, consider alternate methods, but DON’T spread yourself too thin.

Rule #2:  Put your blinders on

This is really “Co-Rule #1” – don’t concern yourself with what other people are doing.  If I had let this happen, I would have wound up wasting money on courses, books, and Qbanks that I didn’t need.  Be thorough, using the LEAST number of quality sources you can manage – know them well, and annotate the hell out of the margins.

This is what my copy of First Aid looked like by the time I was done with it.

Rule #3:  Get your groove on

It’s very difficult to succeed if you bounce around, so fall into a regimen.  This is difficult for people with discipline issues (I watched some of my friends struggle), but force yourself to be a creature of habit for at least 1 month prior to the exam.  At the very least, have your sleep schedule nailed down and do a couple of test day simulations when you’re down to 2 weeks.  (NB:  Don’t actually get your groove on until you finish the exam.)

Rule #4:  Don’t be cocky

Early in your study block, you should allot the same amount of time studying weak and strong topics (you won’t necessarily spend the same amount of time, because you’ll cruise through the things you’re best at).  Around 4 weeks out, a friend asked me why his USMLE World average wasn’t going up, and I asked him how he studied – he was only reviewing questions he got wrong.  Don’t discount the fact that dumb luck may be behind some of those correct answers!  There are also valuable explanations provided by certain Qbanks.  Review everything, and what you’ll do is solidify your knowledge in strong topics (allowing you to answer questions faster, with greater confidence), and build knowledge in weak areas.  When it’s down to the wire, sure, go ahead and ignore everything but the stumbling blocks.

Rule #5:  Keep in touch & decompress when you can

Many medical students isolate themselves to study for the USMLE.  I think it’s fine to isolate yourself physically (I’m most productive alone), but don’t cut off your lines of communication.  I certainly spoke with my friends and family less often, but I didn’t delete my Facebook account or fail to return phone calls (emails are another story).  It may feel like a waste of time, but don’t discredit the value of a good break and what communication can do for your mental well-being.  I may be the first person to say this, but as long as you can control yourself, I think Facebook is a great way to maintain positive communication with friends & family.  I had lots of great laughs at times when I felt like frowning, and I’d bet good money that it improved my score.

Finally, remember that nothing can simulate test day precisely – no matter how well you prepare, there will be things that trip you up and questions you don’t fully understand.  Also remember that this exam is designed to fatigue you – you’re not the only one who’s getting sloppy in the 5th block, but the more you recognize this and fight it, the better off you’ll be.

Good luck, and please leave your feedback/suggestions!


Question strategies:

I see a lot of the following advice – “don’t worry about looking at the answers, read the question and think of what the answer should be first” – that’s fine if you get tricked often, but is otherwise a waste of time.  The strategy that is the most time-saving is the following:  read the first line (often a presentation) so you know who your patient is – then read the last line and peek at the answer choices.  If it’s asking about potential drug reactions, you’ll know what to think about.  If it’s asking about causative organism, the same.  But if you read an entire paragraph blindly, you don’t know what information is important!  This method will help you hone in on the make-or-break facts of the question, and save you lots of time.  For what it’s worth, I had 20 minutes to spare on several blocks.

My predictive scores:

  • Final USMLEworld score – 78%/86th percentile (timed and without topic restriction or recycled questions – important!)
  • Uworld Self Assessment 1:  265
  • Uworld Self Assessment 2:  265
  • Doctors in Training predictive exam:  250
  • School-administered NBME:  95/>260

UPDATE:  I have received many questions about my score and the accuracy of the above predictions.  I will share that I broke a 250 and the predictive scores above were all fairly accurate to +10 points (notice, however, that my scores are tightly grouped – friends who had wide variation were less happy with the predictive value of these tests/formulae).

Selected resources:

Uworld score prediction formula:  2.44 (your % correct) + 70

USMLE Step 1 predictive calculator (use at your own risk):

Great embryo animations/guides:

Not exhaustive; be sure to view full size.

Be sure to know signs of right vs. left heart failure.

My suggestion is to make tons of these types of charts, even if you have them in print. Writing things repeatedly will only help solidify them. Pick one or two to re-draw each night before bed.

My schedule:  I’ll provide a copy of my schedule, but you should create your own.  During DIT, I focused on going through the course as slowly as I needed to in order to ensure I understood everything.  I filled out the workbook completely, annotated it, and marked important pages to review at a later date.  I tried to do at least two full (46 question) USMLEworld tests daily.  I also did not adhere to this schedule 100%, as some topics were pushed to the next day or swapped with shorter chapters to stay on track.

I suggest more than one catch-up day, though I didn’t need it personally.

Posted in: Medicine