Ugh, USMLE Step 1:
Study Tips To Help You Crush the Exam
(but more importantly, stay sane while you do so)
Oh, Step 1…Just thinking about it again is stirring up a lot of repressed emotions and, not gonna lie, some PTSD, but I wanted to provide some solace and potential pointers to those of you about to embark on this Herculean task… studying for the USMLE Step 1 Exam.
First off, a disclaimer:
While I am happy with how I performed on Step 1, everyone is different and there is no magic bullet, no full proof plan that can guarantee a top score. I am honored and humbled that many have asked my advice but these are just my observations and opinions so please read with caution. Being as prepared as possible to the best of your ability (whilst not burning out, going insane, or worse, killing yourself) is key. Another few things that should be mentioned before we dive in, which is obvious but seems to be overlooked, are the following:
A. Your step score is NOT analogous to your IQ score. Your step1 score DOES NOT correlate to your level of intelligence, nor does it represent anything about you as a soon to be doctor, academic, or human being. DO NOT FEED INTO THAT NEGATIVE MENTALITY. You are smart, there’s no way you’d be sitting for Step if you weren’t.
B. It is one exam, even the brightest, top of the top students can have a shitty day (which is why they look at other factors as well). You do not need to add to your stress by assuming that how you do on this one test will solely determine your future, in most cases, it will not.
C. Step 1 is designed to test “minimal medical competence” meaning, any score above passing indicates minimal competence. A score of 275 does not mean you are more minimally competent than the kid who got 205. Tests beget tests, but honestly mean very little on the scale of how good of a doctor you are or will become.
D. Lastly, and perhaps most poignantly, a program directer at a highly respected institution said the following to me: “Do you know what a Step 1 score of 250 tells me about the kind of doctor an applicant will be? NOTHING. We use these scores to ensure that our accepted applicants will pass the residency boards (which the pass rate is typically in the low to mid 90s at most respected institutions). So we need to see a solid score, BUT when I look and see that an applicant honored most or all of their clinical rotations, has strong letters of rec etc- that means they know how to interact with people, with patients and colleagues- they have that “magic.” I can teach you how to pass multiple choice exams, but I cannot teach you how to be a human-being at the bedside.” That stayed with me and resonated deeply as I hope it will for you too.
OK! now that is out of the way, the sad and archaic truth is, for certain residencies and certain programs, you do need to hit a certain score. I will tell you how I prepared as well as how some of my peers (who did better than me) did, but keep in mind, everyone is different and its about knowing how you best digest/recall large swaths of information.
SO HOW DO YOU GO ABOUT IT?!
1. HOW MUCH TIME DO I DEDICATE TO STEP1 PREP?
-This will be a little different depending on your institution and how much “vacation” time you want/need. My institution gave us 8 weeks to split up as we wished. Most students take ~6weeks for dedicated study time, then have a two week break before starting clinical rotations (our MS3 year). It seemed that the sweet spot was somewhere between 5 and 6 weeks for dedicated studying. You need to find the balance where you aren’t forgetting material from your first week of studying but still have enough time to cover it all. You can also push your test date back as well, but I’d recommend against that unless you are scoring very low on your practice tests. In fact, I’d highly recommend buying plane tickets to a beautiful place so that you not only have something to look forward to, but then you really can’t move your test date. I personally gave myself 5 and half weeks for dedicated study which I felt was sufficient and the last 3-4 days I was so anxious that I didn’t really do much real studying.
-Definitely make a detailed schedule, block EVERYTHING out and stick to it.
2. OK FINE, I SET ASIDE X WEEKS, NOW TELL ME WHAT DO I USE TO STUDY, DAMNIT?! TELL ME!
-There are literally hundreds of study resources and I certainly cannot speak to all of them. Regardless of which resources you pick, DO NOT OVERDO IT! There is only 24hrs in a day, use them wisely. Resist the temptation to buy anything and everything that has a “Step1” title and limit yourself to ONE question bank, ONE master review book, and ONE microbio/pathology/pharm resource- MAX. [Keep in mind there is the pricey alternative of a review course like DOCTORS IN TRAINING- If you are someone that needs more hand holding and structure, I’d go for DIT, but also know that you may need to build in an extra week or so to get through DIT.]
https://www.doctorsintraining.com/
Your PRIMARY learning/review/prep/golden nugget/lover/bed fellow, will be your comprehensive question bank. The one most use and swear by is USMLEWorld aka UWorld aka World aka I never want to open that godforsakin thing again (oh right, step3 😳 – update: passed Step3! smell ya later Uworld!). Uworld has something like 2,200 questions which are HARD AS BALLS and are laid out exactly as the actual test. What makes this resource invaluable though, are the explanations- for every answer choice not just the correct one. This is the meat and potatoes friends, in fact, I know kids who literally just used Uworld and did it 3x and reviewed every last word of it and crushed boards. While I learn best from questions, i needed a little extra organization personally. Now, if possible (without driving yourself insane) I would try to start using Uworld in the second year (or whatever year you do your clinical medicine book learning prior to clinical rotations)- doing a block of cardio questions during your cardio block etc (i’m talking like 5 questions a day kinda thing). Keep in mind, you will likely get many of them wrong, expect that and be OK with that, you are just getting the flavor. That way youll have made it through all (or most) of the questions before even starting dedicated Step1 prep- hit reset and do it all over again. Some feel they will remember the correct answers and bla bla bla but if you are using UWolrd as a study tool and not just trying for a high score, youll be golden because you will be reading the explanations and LEARNING. Plus, who the hell can remember 2,200 right answers? While step studying, I’d highly recommend using the mixed/random option so the questions can come from any and all categories. Why you ask? Oh, I’ll tell ya: Because if you do endocrine the first week, by the end of the 6 weeks you forgot it all plus the test is random like that and not throwing all the pulm q’s at you in one block- try to emulate the test as much as possible. Now, I was also told this advice about reading every explanation etc and I did at first, but its taxing- like really taxing, and I should have been more vigilant about it. I was too focused on getting through all of the questions –DONT MAKE THAT MISTAKE! read everything. EVERYTHING. E V E R Y T H I N G. ALL OF IT. Some will keep a spreadsheet of what they got wrong, the learning point, and ways to remember. I did not do that, instead I would find the corresponding section of First Aid and jot down what I learned from UWorld (more on that to come).
One last point: Do not get caught up on your raw score on these Uworld blocks and recognize the average is usually low to mid 60%s- they are hard for a reason. Also, do not overly read into the correlations of Uworld percentage and Step1 scores online too much, youll go nuts and too many gunner nut jobs are on the internet shouting about their calculations for projecting their scores and I just don’t believe it so all it will do is make you sad or anxious or miserable or all three. So better to just stay away.
To review:
-Buy Uworld as an MS2 (or a year before you plan to sit for Step1), do questions related to coursework as you go (but don’t go nuts)
-During dedicated Step prep: do questions on random in blocks like the test-read ALL the explanations. ALL I SAID!
-Attempt to get thru it 2x, but don’t rush it’s better to do it once but very thoroughly
REVIEW BOOKS:
-Most will opt for FIRST AID FOR THE USMLE STEP1 (most current edition) (AKA FA). Honestly, I wasn’t a huuuuge fan of the book as a stand alone but in conjunction with Uworld, its helpful. It’s literally facts on a page in short hand with some helpful (and some not so helpful) mnemonics mixed in. Here is the key: Make the book your own– that is where the money is. It comes as a soft cover bound book, so I actually went over to Kinkos or Staples and had it spiral bound to make it more durable and easier to flip through. I then bought tiny post it notes in different colors and made tabs for the different sections to make finding what I needed more efficient.
First Aid was my “master” book where I’d consolidate everything. I’d draw in it, mark it up, add sticky notes etc. The most helpful for me was using it as the place where id write in what I learned from UWorld explanations in the corresponding chapter of FA. In a perfect world, I would read a chapter or two in the AM then do 2 or 3 Uworld blocks, annotating my FA as I went. That night if i was feeling particularly ambitious, I would review my annotations. Be aware, FA should NOT be a stand alone review book, while its *relatively* comprehensive, its not gonna cut it as a solo prep. I also HIGHLY recommend tying in your school notes into topics you are reviewing, many times those notes will be the first thing your mind conjures up so revisiting those and putting them into your FA is nice.
3. HOW ABOUT ALL THESE VIDEO BASED LEARNING TOOLS?!
-When I was in my second year of med school (circa 2015), a miraculous thing happened: Sketchy Micro came out (now known as sketchymedical). It was as if a baby unicorn was born and slid down a rainbow, wrapped its tiny baby unicorn hoofs around me and whispered in my ear with its cotton candy breath, “we got this.” It poops skittles. Ok, I digress, anyway- I’m a very visual guy and was essentially making my own visual notes and puns to help me study throughout all of med school and when this product came out, it all fell into place. I highly recommend it during your microbiology/ID block and then review it a few more times during dedicated Step prep. Since then, they have made a sketchy pharm and path and all the things. Its a truly wonderful product- so wonderful I actually considered postponing residency to work for them.
A warning: you may not be this kind of learner in which case opt for something more traditional- such as Pathoma. Pathoma is an INCREDIBLE video lecture series taught by the ever talented Dr Sattar who has a gift for breaking down difficult concepts. He will teach you path so well you’ll wonder why you’re paying so much for med school. I used both sketchy and pathoma during the year and then during dedicated Step prep, when I got fatigued by Uworld and FA, I’d pop on a sketchy or Pathoma video and review it. There were countless nights I was lolled to sleep by the sweet croonings of Dr Sattar.
4. SO, I STUDY 16hrs DAY DONT EAT OR SLEEP, RIGHT?
-Nope. Wrong. Very wrong. Think of your brain like a plant- you want it to grow into a huge friggin’ knowledge tree- like MASSIVE with numerous leaves full of all the med things. But if you flood it with knowledge water, itll drown. It needs sunlight, healthy soil, an active sex life- you know, all the things. Don’t over do it. Make a schedule that has built in break time, meal time, bed time, exercise time, and flex time and stick to it! Not only will you be able to absorb more info that way, you’ll consolidate and retain better. Also- and this is key- stress/anxiety release toxic amounts of glucocorticoids into your blood stream- these stress hormones will cloud your cognition, make you fat and irritable, not to mention hyperglycemic (if youve got the ‘betes like me). That shit is deadly to that knowledge tree you are trying to nurture. I forced myself to go for a run every afternoon (not a far run, mind you- I hate running) but it got my blood pumping, gave me some vitamin D, and helped me stay sane. Find your thing. You do yoga? Do yoga! You spin? Go spin! You sit on the couch and binge watch shitty Netflix shows? Have at it! Also, try to eat healthy- lots of fruits/veggies, low glycemic index complex carbs, plenty of protein (fish, beans) and stay hydrated. Perhaps most importantly: CAFFEINATE OFTEN AND PRN. I would do an iced red eye (iced coffee with a shot of esspresso) at 7AM and then a small iced coffee at 1PM for that afternoon slump. I tried to stay away from caffeine after 2PM.
5. GOT IT! EAT, PRAY, STUDY BUT WHERE IS BEST TO DO ALL THIS?
– Many will opt for the library but I found that being around so many other med kids w their FA and UWorld open around me not to mention the palpable anxiety making the air thick- I said “nuh uh” and found a secret “study hole” I affectionately dubbed “the study dungeon.” It was in one of the lesser used med ed buildings and had a 4 cubicle, clean, silent room which was windowless (that sucked) but it was home-base for 6 weeks. I told a select few homies about it and we kept it our little secret. On the weekends, I’d study at my local coffeeshop to mix it up and to remember what other humans looked like. All that being said, if you’re a library person- go for it. There is some data to suggest recalling material is easier if you are in the same environment where you first learned it.
A word on motivation- in your cubbyhole/cubical/desk/dungeon hang up a note, a picture, quote, some form of reminder of the goal you’re working toward, some motivational image- something. When I was in my post-bac pre med program a friend and I hired an MCAT tutor that we shared. He was harsh and prided himself on his track record for getting his students into med school, when he took a look at my grades and practice MCATs, he called me, literally the day before the MCAT, and said DO NOT TAKE IT. I believe his exact words were “you have zero chance of getting into medical school and I doubt you will do well on the MCAT, you aren’t meant for med school.” I hung a picture of that gentleman in my cubicle. Sometimes its the haters that motivate you the most. “I had someone tell me I fell off, ooh I needed that.”
6. GOT IT, ENOUGH W THE WARM AND FUZZY BS-HOW DO I KNOW HOW IM READY?
– There are a handful of NBME practice exams which I THINK* were actual official previous exams. In addition, there are 2 Uworld practice exams. All of which are for purchase. The NBME exams I think are most indicative of how you’ll do. Some like to start off with a practice exam before their dedicated step prep time to get a basis of where they are at baseline. If you do, recognize you may get somewhere between 170-225 and that’s ok. I’d then take another one two weeks later and then spread maybe 2 or 3 more out with the last one taken NO less than ~one week before the exam. If you notice a downward trajectory- regroup, reassess, and consider pushing your date back. NOTE- The NBME practice exams do NOT come with an answer key, what I did was round up a couple of my brilliant friends and we’d review them together and talk through answers.
A personal story to put your mind at ease: i took a baseline test about a week before my dedicated step prep time and shocked myself by how well I did. About a week into my study prep, I figured I’d see how much I improved- well, I went down. DOWN?! Good lord, I freaked out. Took another practice exam maybe 10 days later.. it came up, but ever so little. Another week later, I had plateaued at a very average score. I thought I was doomed. Well, my actual step score ended up being ~15-20 points higher than the last NBME practice test. As will yours. I hope.
7. TEST DAY IS FAST APPROACHING, IM POOPING MY PANTS, LAST MINUTE CRAM SESH?
-Nope. I took the last day off and treated myself to the movies. It was a weekday in the summer in Philly. I was literally the only person in the theater. It was glorious. Got my mind off of things. I went home, laid out my sweats, got my things in order. Checked my permit, photo ID, packed snacks, curled up in a ball and rocked back and forth for a bit. Set 7 alarms, then went to bed. Ok fine, maybe I laid in bed for 8hrs with my eyes wide open, but whatever you get it.
8. DOOMS DAY. ITS HERE!
-You prepared, now just relax, click the right answers, and CRUSH. Leave test center, do NOT google anything, DO NOT listen to that tiny voice who is saying “shit, i just failed,”
DO buy some whiskey, DO eat a huge cheeseburger while in your underpants on the couch, DO cry like a small child if the mood strikes, and DO get on that plane to a tropical vacation and forget ALL the things.
Congrats, you made it!
Besos,
Mike Natter, MD
Mike Natter Medical: Artist. Humanist. Doctor. 
I just finished reading this and find it kinda funny regarding how some things haven’t changed over the past 17 years when I took this test. We all have the same insecurities re: test-taking abilities, worthiness of even taking the test, and concerns about our source of information for studying. I also think it’s interesting the fact that everyone has a different way of organizing him/herself, as I always say “you and only you know yourself”. I was always a firm believer of state-dependent memory…I used this strategy and it helped me, not only study better, but to know myself much better. One thing I’d add as part of this whole process of Step1 (2,3) is **acknowledge the need for supports** supports can be your family, your best friend-either medically or non-medically related, the secretary, the janitor ,or, in my case, the cash register who would always save me some candy (shh, this was a secret). In the long run, tests and their scores won’t determine your path in life, so don’t be too focused on them (ok, be focused, but don’t be myopic about them) 🙂
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