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My USMLE Step 1 Experience: 261/99 (WOW)

By Unknown - Tuesday, July 5, 2011 1 Comment

Status: 6th year medical student at a university in Romania
Target score:250+
Final score: 261/99

Exam date: 12.1 received score: 12.22
Total prep time: 1 year 1/2 - effective prep 9 months

I have to explain this part a bit. My still being a student, and hence with recent contact (well not THAT recent) with basic sciences might have helped me out a bit. But the lack of clinical experience is also to be taken into consideration. My total prep time was that long, atypical for most exam takers, for a few reasons. I started in March 2009 reading around in forums about materials used and general guidelines regarding prep (while I was in my 4th year). I gathered books (downloading a few, buying others) step wise. This means I first used Kaplan lecture notes and FA, read through a subject (see description below) and then decided if I needed any extra material. Looked up ratings on these forums and Amazon and bought it. This was not a classical first read, it was more of a recon mission...I also color code and underline everything that I read so yeah it took abnormally long to gather everything, orient myself and really start my prep: almost a year. Thus I hope my experience may help a bit in shortening this process. At the end of my 4th year I only had cards, respiratory, gastro as major rotations. I felt the need to go through hematology and neurology and I was right, that helped out a lot. I don't think it's a must to have had clinical rotations since AMGs have this exam at the end of their first two years without any clinical contact...but it certainly does make your life easier, know how to read faster through questions, what to look for, how to judge in a certain know, just allow you to focus to answer the question without getting tangled up in details which is very important and I'll explain later.

One more thing...I do not think that the time allotted for your prep is essential. I only got to study for the step 2-3 hours per day weekdays and about 9-10 hours weekends, had quite a few breaks because of school exams (like peds-very long) and started real study in my summer vacation. Those 9 months (March 2010 - December 2010) are more like 6 months total.
So it's really difficult to answer questions of how much time is need...depends on many factors, your prep style, your background (since I took my classes really serious even during my step prep) etc.

Materials used:
0. First Aid (FA) - 2009
1. Pathology: Goljan RR(Rapid Review)(2nd edition), Goljan Audios and Slides, Webpath (free internet pathology slides)
2. Biochemistry: Kaplan lecture notes(2007), videos:Lionel Raymond(2002)
3. Cell and molecular biology/genetics: Kaplan lecture notes(2007), videos:Lionel Raymond(2002), High Yield Cell and molecular biology (Ronald Dudek-2nd edition)
4. Microbiology: Microbiology made ridiculously simple (MMRS), Kaplan lecture notes, no videos
5. Immunology: Kaplan lecture notes, no videos
6. Physiology: BRS Physiology (Linda S.Costanzo), Kaplan lecture notes(2008), no videos
7. Anatomy: Kaplan lecture notes(2007), USMLE Road map Gross Anatomy (White), High Yield Neuroanatomy (Fix), Netter atlas
8. Behavioral and biostatistics: Kaplan lecture notes(2008), BRS Behavioral (Barbara Fadem), Conrad Fischer Ethics
9. Heart sounds: ;
10. CTs: ;
11. Angiograms:

Question banks and self assessments:
1. Kaplan Qbank (8 months before exam-2 months time to finish): 70%
2. USMLE World (UW)(5 months before exam – 4 months time to finish): 80%

3. NBMEs
NBME 1 (7 weeks out):630/251
NBME 2 (6 weeks out):610/247
NBME 3 (5 weeks out):640/253
NBME 4 (4 weeks out):670/260
NBME 5 (3 weeks out):630/251
NBME 6 extended feedback(12 days out):680/262-11 mistakes
NBME 7 extended feedback(11 days out):670/260-13 mistakes
4. UWSA (self assessment)1:800/265; UWSA2:800/265 – did these two 10 days before my exam back to back in an 8h session to see if my performance drops in time because of fatigue, see how breaks work for me etc(even had a quick lunch). It went up, because UWSA 2 is easier actually.

After gathering materials and going through them once, as described above, I really started my prep. I listened to Goljan audios in the summer of 2009 to have an idea of what lectures mean (since Goljan is the gold standard). Awesome indeed, a must must must, even just for fun. Gave it to all my med school friends who aren’t even preparing for this exam. Gives you insight, teaches you how to learn. I did not have time to listen to him again, but i still remember 70% of it.

The order of subjects and books listed above is the order I used to study.

Started with pathology, the biggest and most important subject as most people I needed to really have a firm grasp here. Starting early meant I could go through path a couple of times. Read Rapid Review in a month or so (March to mid April), an easy task, since I find path easy, and I knew many (most?) stuff in the book from my clinical rotations. Path was actually easiest for me to learn. Why 2nd edition? because I had bought it before the 3rd came out, I guess the best is always the newest but I did not have time/money for that, already color coded it (imp to me and time consuming). Looked sporadically at webpath slides since I did not have much time due to school work. Read a chapter or two twice each evening. Again I must stress the fact that the number of readings isn’t all that important, just focus on what you are reading. Slides are really important, many images in the exam (yep,mostly gross) I looked at Goljan slides a day before my exam too.

In mid April I started reading biochem, a subject I loved in med school. I already knew from my scouting for books that much information (if not all) had vanished since my first year, so I was ready for a rough patch. I believe that multiple readings here, during different prep times are the way to go, info is really volatile and if you integrate it with pharm and path it will help a lot. That is why I started biochem so early. (word of caution here: be ready to have a general view on all pathways and know how to link one to the other...I had two questions that needed integration of all three major pathways: protein, lipid and glucose).

Biochemistry includes the really difficult part of molecular biology. I knew it might be heavily tested (Oh boy and it was) so I read High Yield Cell and Molecular...first time it was really difficult, since it has a lot of info that you needn't (and cannot) memorize, but it helps, a lot, trust me... read it again 3 weaks before my exam after going through everything at least once to try and integrate info. I suggest reading this book (had the 2nd edition, dunno about the first seemed a bit to old) and try to understand stuff in there ...questions in my exam were near to impossible in this section, info nowhere to be found (trust me), so I had to make educated guesses to the best of my is where this book steps up. After going through biochem once I knew that all the pathways will vanish into thin air, so I used this first time to understand, make a few correlations. Cell biology mainly sticks with you after the first time, but you really have to have a general view on all processes here.

During these two months (March-April) I also read FA cover to cover...see how much in that book is familiar (about 70% ), know where everything is etc. While studying any subject (except path) I had FA open next to me and looked up the info there after I read (and understood) something in the lecture notes.

Mid April I started Kaplan Qbank...I do suggest you do this qbank, I really think it is really useful in two aspects (and difficult ones at that) :1. Molecular biology and genetics, really difficult questions here with much labwork (RFLPs, DNA sequencing etc.), well explained in the videos; 2.Microbiology – maybe not that similar to the real exam,but huge help in learning stuff, mainly bacteria and virus descriptions (lactase positive, oxidase positive, dsDNA enveloped, helical etc.). Behavioral is really good also (even better than UW I suppose). Took me two months to finish (also read in parallel and much school work to be done peds rotation started, a long one, so I decided this was the time to squeeze in a qbank). This qbank has references to FA so that was really useful, was like reading selectively from FA. I also made my own notes, round 120 pages that will prove useful in the end.
One more detail...did both qbanks the same way...tutor,random,unused. Why tutor? because once you choose an answer in tutor you cannot change it. I wanted to be this certain of an answer in my real exam: when I choose something, to be my best idea for that question (I’ll explain why later). I timed myself every time so that it did not take me more than 35-40 min for a 48 question block. And yeah, I started a qbank before I went through most of the subjects...because this is what I believe means to „use as a learning tool”(love this phrase ). See how your learning gauges up (or not) the performance in that particular subject, and taking notes of what seems extra and important info.

The same time I started reading Micro from MMRS. It was neat seeing how my performance in the qbank went up as I advanced in micro readings. (from around 60% to nearly 75% , low, mainly because of physio). MMRS is fun to read, useful as a start, really gives a great foundation. Do use FA in parallel with the best mnemonics ever. (yes I suppose most of the info you really need to know is in FA...most). Finished MMRS (it is quite big, round 400 pages, even with the funny pictures and all) in 3 weeks and started immuno (really important subject!). Went fast, 1 ½ weeks, Kaplan seemed enough. what does enough mean? to me it means I understand most of it and I can answer around 80-90% of questions in any qbank (doing kaplan at that time).

Did not mention a few breaks in this schedule because of school exams. After another study break (1 ½ months) summer break came (mid July). I was on track. Subscribed to UW for 3 months (got an extension later), started doing questions, really slow progress, a max of 30 questions per day (well 48 answered in the same way, tutor, random, unused / 30 by going through all the answered, right and wrong). Wrote a lot of extra info that i considered to be important in two notebooks (about 160 pages) which what seemed to me to be VERY important as I jotted down in my FA. I know I know, how does one decide what is important or not. What I believed is info that can be forgotten I it wrote down in my FA, pathophysiology (like heart sounds and details about the OS) and smaller details in the notebook. You should get the hang of it in time, see what works for you.

I had the 2009 version of FA. After finishing UW and with quite a few new details written down in it i compared it to the 2010 version, everything (and I mean everything) they added in the 2010 FA (and even on the same pages) I had already written down.

Mid July started Pharmacology which was kind of easy for me, remembered many details from my courses in school and I paid attention to mode of action (MOA) and adverse effects and It took me 2 weeks, only Kaplan. FA in parallel, cancer drugs and immuno drugs are vicious to remember and high yield (did they throw a weird drug at me in my exam? yes they did, asked MOA, did not recognize the name, recognized the type by looking at its suffix). UW helps with details here, especially CNS pharm.

August meant BRS and Kaplan Physiology easy to learn, easy to remember, important to understand. Yes, do use both books, they really complement each other nicely. Kaplan has many weird graphs you do not need to learn but really help in learning how to read graphs in general (had a really weird never before seen graph in my exam aswell). took 2 weeks off...vacation and a trip (really needed!) .good performance (along with path and pharm and cell and molecular) in my exam here.

In September I started Anatomy. First Road Map (I know, lots of info, not all needed but do read it at least once), since I knew Kaplan is shallow in gross anatomy (embryo is enough trust me!). I also tore up my Netter atlas and selected some images there...learn anatomy (pathology as well!) by seeing things, take advantage of this fact (unlike immuno or biochem). Look up CTs/MRIs. Neuroanatomy is excellent in Kaplan, helps you really understand the processes (not just memorize them) and it is way easier to learn than the gross part. Love neuroanatomy, and it is also a vital topic which went easy and fast. I read High Yield neuro to brush up on small details. Total time for anatomy was 3 weeks.

Because I was on my summer vacation I had all the time in the world now (finally). I used to put in round 10 h study time per day. Subject of the day, UW questions and reading answers (painfully slow tho!), and some vids: July-mid August biochem (LIONEL RAYMON...Google him! awesome awesome awesome, really useful!), mid August- end October pharm (LIONEL RAYMON same same same).I did vids separately from reading that particular subject because I tried to have as little gaps as possible for subjects; i tried to constantly read something from every subject in a week. That is why I decided to start a recap before I finished anatomy and behavioral. So I added up to my daily plan, starting august, a recap of biochem (only Kaplan), path and micro (Kaplan notes- had not read this before, and it is useful in bacterial genetics!!)=+ 2h study time/day. Wanted to go through them one more time before school started (October) and I did.

Behavioral; last but oh so not least 3 weeks. Read Kaplan (no time for vids unfortunately). Still had trouble doing questions. I did not have time for an extra book in statistics, so i used Kaplan and UW (really imp-my FA section doubled in statistics). I also did Fischer Ethics in 2 days (easy read) but still with trouble in questions. This infuriated me, decided to buy BRS...yep, this kind of solved my problem and I read it later on in my final prep time (November), but it helped a lot. I could finally see my NBME behavioral moving away from borderline (my only borderline). Truth been told there is no secret book for this! Ssee what works for you. Questions can be really twisted here and I struggled with many in my exam.

Finished first read of all subjects in October. Decided to go through everything again in 5 weeks. school started so things were crowded again. Everyday I revised a particular subject-round 80 pages per day (Monday-Sunday): Biochem, Physio, Micro, Anatomy, Behavioral, Path, Immuno+Pharm. As i read these I had my FA open...I jotted down some extra info from Kaplan and the other books (info that i did not remember or was fuzzy from my previous read/s) In addition, every Saturday I took an NBME (scores increased gradually as one can see above). This recap drained me.

I decided to take three weeks (last three weeks) off from school (don’t ask how) for my final prep. Read FA and my 3 ½ UW+Qbank notebooks. Last three weeks were a 14h deal. Also looked up CTs MRIs and some webpath along the way. Had to travel to Holland for my exam, this helped with the anxiety a bit. Last three days i.e after finishing FA, I decided there was simply not enough time or energy to go through FA again. So I read my UW notesagain, and, while reading, looked up stuff in FA. This helped a lot. It was mainly because I simply could not decide even after all the NBMEs what my specific weaknesses or strenghts were. Why? because of this integrative style...while my biochem, cell, physio, path, pharm, micro had stars, cardio or resp or general principles were a bit lower.

Final word for prep...I do not know if you HAVE to use ALL of these books. Most people suggest you stick to one set. I felt the need to fill some gaps so I bought the extra books, and that made a difference to me. See what works for you...if you are unsure of a subject search alternatives (before it is too late), these were the best alternatives I found by reading posts like this. It was hard work but I loved, literally, every minute of my prep, cause I felt things becoming clear and adding up. And started diagnosing rare disease in school during rotations..Awesome... And I did have a life (some at least) went out Friday nights and Saturday nights (not very fresh for my NBME's huh?), played football etc. Do those, keep a balance or you'll go mad (like I felt during those last 3 weeks).

Really REALLY hard. No, not because it was THE exam, not even because it was MY exam. Wasn’t nervous at all, had a 7h night sleep, breakfast etc. It is just that, while reading around in forums I found out that some people have a slightly atypical exam: way tougher, with recent research, long questions etc. (the ones that get a 99 with 229 I suppose-just a wild guess not something certain of course) Hoped it won’t be mine, but was prepared for that (no, actually, not really). Cannot disclose particular questions but I'll give you a few examples.

Don’t want to scare people, or complain, or find excuses, just be sure you are ready for this. Most people say they have one hard block with long questions. Many easy questions alongside, a few difficult ones, 5% impossible questions. NBME style exactly. Not this one.

I had a slightly different system in solving questions that worked really well in all NBME’s and UWSA. I finished all 46 questions (well 50 in NBME) in 30 -35 mins. left 2-3 unanswered if I really had no clue and I tackled those after finishing the block (decide on an answer in max 5 mins). Did so, in order not to lose focus, think too much about one, and get tired for the others. Marked around 20 questions that seemed tricky or needed further attention and reviewed those till the end of the time for that block. During my exam I succeeded in answering in that 30-35 mins self imposed time gap. No random choosing but many many questions, maybe 80%, even more, had huge question stems. Never had an issue with reading stems but they slowly add up in a 7h exam. Really drains one out.

About the difficulty...lemme put it this way: I marked 35 questions give or take for further reviewing. No, again, not because it was the real deal and I wanted to be sure but because questions were incredibly difficult and twisted. Many details, like side effects of antimalarials (really?), dengue fever...yeah micro, the subject I used to be really sure of (had 90% in UW) was unbelievably hard. Not to mention the always present cell and molecular...things never ever seen before (guess my guesses were mostly correct since my profile shows a star here huh). Yeah, in behavioral you always always ended up with two equally good choices (BRS did wonders, got a star here too), couple of twisted graphs in phys. Biostat with few calculations, but many many conceptual questions. Neuroanatomy was big (look up CT’s, know even the slightest detail on them-High Yield Neuro). All in all pathology seemed to be prevalent but I actually believe they were evenly distributed or sure seemed like it (even behavioral), maybe a bit lower on pharm questions. Truth is I could not classify many of the questions as being simply this or that subject. 2 heart sounds (one answer using the stem, the other could be answered only by listening), no sequence questions at all.

Breaks...use them! Did first two blocks in a row, took a 10 min break to recover. I knew what was to follow so I decided to overcome the initial panic and just do my best. Washed my eyes during every break, drank a coke (diuretic, use with caution!) and some water, ate some chocolate. Took a break after every block (5-10 mins), not necessarily because I was tired but I forced myself too in order to recover focus. Managed not to think about previous questions during breaks (too much).

Moral of the story...I am not exaggerating here (certainly do not believe so at least) but you can be the unlucky one that gets this type of exam (or worse?) prepared to read long stems (many if not most!), be prepared to improvise (answer without really knowing details of that-giving examples would explain this better but as you know I cannot do that), be prepared to face questions from recent research (no, this does NOT mean you HAVE to read recent articles), be prepared not to be able to answer questions fast like in the NBME’s (i.e based solely on knowledge) prepared means morally prepared (don’t panic!!!) because I do not think there is a way (or enough time) to be ready for these exams. I do not know if in a different exam I could have broken the 265, but it would have been certainly more possible. Needless to say how I felt coming out of the test center.

Take everything I say (and everyone else for that matter) with a pinch of salt. For me it was a difficult exam, for which I couldn’t have prepared much more better in this 9 month time frame. Just be ready for everything, expect the worst and you will be more than fine. Again, I do not know how much time one needs to be prepared, or which books are best or how many readings are necessary. Different people, different ways. The exam is hard but with hard work and wits anyone can do it.

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