USMLE Step 1 Study Tips

Jeremy Pyle, UI-Peoria, Class of 2005

Caveat #1: This is entirely my opinion and should be evaluated as such. I’m wrong a great deal and my intentions in writing this are to help a select group of people who relate to my situation without irritating the rest.

Caveat #2: This is long.

Before detailing my approach to Step One you should understand that there was a reason for my excess. A series of reasons, I guess.

I was disappointed with my performance during my first year. I figured that working excessively in preparation would allow me to relearn some of what I had forgotten and eventually make me a better doctor. For me this was a big point. If you asked me to study 16 hours a day for a test that would mean nothing to my career I would tell you to leave me alone. Believing as I do that core science is important to knowing human pathophysiology makes working a little harder to become a better doctor worthwhile.
I had a little extra motivation: my fiancée is going to be a third-year medical student in Indiana when I start residency and I would like her to be able to transfer so that we might be together. I figure the more enticing a candidate I am the easier that will be. I have no reason to believe this is true, it’s just my hope and, for the most part, her demand.

So here, in brief, is the approach I used and lessons I learned.

Questions are as dangerous as they are helpful. They are a critical part of preparing for how one will approach the actual exam and a prepared student must feel comfortable with the format of an exam. That being said, after one has done enough of them to feel comfortable they are, in my opinion, excessively time consuming. One can spend an hour doing a 50-question block and two hours reviewing and learning the rationale behind the answers and before one knows it, three hours are past and only fifty concepts have been evaluated. If one reads ten pages an hour in a review book, that translates into 30 pages of text in which one will most likely find more than fifty pieces of information organized logically and coherently so that one topic breeds understanding of the next. In my opinion, questions are for learning how to take the exam, texts are for learning what knowledge to apply. That being said, a series of questions was quite helpful in breaking the monotony of review books.
The theory that one should take a full 7-hour exam near to the actual test date is something that I don’t fully agree with. This is in part based on the above reasoning and that it’s hard to take and learn everything from 350 questions in one day. The rest of my reasoning is based in my belief that nothing you can do in a one-day setting will prepare you for the actual exam. It is grueling but you have a reason to stick it out and focus on the actual test day. This is difficult to enact in a dry run. So in my opinion spending 7 hours the week before the exam studying pharmacology on a deeper level (using pharm to represent a very detail-oriented part of the exam where the little things can be easily forgotten) may be of greater value. I never did more than about 150 questions in a day. To train myself instead I would do increasingly longer blocks of questions without breaks. I would take and review first 50, then 100 questions without a break, then 150. This approach is based loosely on the way a marathoner prepares for a race, by building up to but never actually running 26 miles.
The NBME has 150 questions on its website. Do these questions until you are comfortable with the knowledge purveyed in most of them. More than a few of these questions were on my exam in a format remarkably near to the practice exam. Extraodinarily high yield.
I woke up every day between 5 and 5:30 (6:30 on Sundays) and began studying as soon as was possible. I went to bed at 11:00 or 11:30. I studied every minute of every day that I had during the summer. This was possible because I used a similar ethic during the first two school years where extracurriculars forced me to use all excess time wisely. To blow off the first two years and then try and study 18 hours a day will likely lead one to a psych ward. The boards is not a battle won in 5 weeks.

If you sit down and evaluate your day, something I would highly suggest you do early in the game, I think you will find a lot of time wasted that, for the 4 or 5 weeks before boards, can be extraordinarily valuable. For example, I’m an idiot in the morning but reviewed hematologic pathology and cancer every day during my morning shower. This sounds ridiculous I agree, but it meant that not once did I have to devote an afternoon or a morning to that very high-yield material and I knew most of what they asked about it on the exam. By spreading the material out over 5 weeks I was able to review it again and again and supercede the fact that I only remembered 10–15% after any particular morning. That helped me.

It’s like this: if you spend an hour every night over dinner and watching a TV show during the school year, then you cut that down to 30 minutes during the 5 or so weeks before boards, that’s 30 extra minutes, 7 days a week, over 5 weeks, or 18 extra hours in toto. Do you know how much you can learn in 18 hours!
I spent the time between tasks as productively as I could. If one reviews hundreds, maybe thousands of pages of material before the boards, remembering all or most of that material is not possible. In addition, as is the way life goes, some days are better than others. On days when I was getting frustrated and didn’t feel like I was retaining enough (probably 3 of 5 days were like this), I would write down short phrases to spark my memory and review them while I was walking around. In addition I tried to spend the last couple hours of every day reviewing things I had learned up until that point. Sometimes being comfortable with one’s knowledge is as helpful as simply having a catalog of facts memorized but with no ability to be used.
You know yourself better than I do. I would urge you to listen sometimes when your body tells you or your mind tells you to slow down and relax. At the same time, listening all of the time during an event as stressful as the boards can lead to excess time off and minimal time on. As they say, when the going gets tough the tough get going.
Finally, your score will shape but not dictate your residency options. People have gotten into great programs with average scores and not gotten into average programs with great scores. It is my opinion that a good board score will open more doors than will almost any other thing you can do in your first two years of medical school. If there is a time to transcend your tendency towards distraction, or your need to watch ER every week, this is it.

Resource Breakdown

Things you should know in advance: I read every resource on here at least twice, most of them three times. The value of these resources, in my opinion, is as much in how you use them as in what you use. No one can predict the makeup of the exam he or she will be given. Knowing this, my approach was that what I studied was less important than how and how hard I studied. My goal was to memorize as much information as I was capable of while forming as complex a set of relationships between the pieces memorized as possible. I figured that by doing this I could predict the questions they might ask. Turns out that some of the questions (15% or so) were predictable, but the real value in this approach was that it forced me to think harder than I was previously capable of thinking; thus it allowed me to get smarter. I learned a great deal while studying for boards.

Many of these resources got high ranking in the back of the First Aid book, which I used along with advice from current M4s to shape my list of resources. Speaking of First Aid, the back cover says something along the lines of “Your SECRET weapon for the boards, used by 216,000 people in the last twenty minutes” and for the most part, I think it’s a mediocre book. Concepts, not facts, make the hardest boards questions.

Anatomy: First Aid, also used Netter during the organ segments, but not faithfully. Anatomy, for me, was a huge subject with a lot I didn’t know and a few topics that I knew would be heavily tested. You can be pretty well assured that you’re going to get a question on the brachial plexus and major nerves of the arm and hand. You can expect questions on the anatomy of the abdomen. Also, what I kept finding were little pieces of clinical anatomy that kept surfacing, like: where does testicular cancer metastasize to first, where does prostate cancer metastasize to, what nerve is impacted in a crush injury to different parts of the elbow. You’ll see when you study. I read part of High-Yield Anatomy over break this year and found it to be very useful for third year, but probably not really useful for the boards. Plus it’s 180 pages and most of my anatomy questions could have been answered by reading 40 very well-selected pages (arms, hands, abdomen, GU and probably a few others I’m forgetting).

Embryo: High-Yield Embryology as my main text supplemented with First Aid. I did more embryo than anatomy. I felt that much of anatomy could be guessed well if you understood the embryo and its development and most of the embryology that was important was in this book. I would say this was a good strategy for me, but it was fairly unique and unorthodox. I don’t remember a lot of embryo being on my exam but everyone’s test is unique.

Biochemistry: High-Yield was my main resource, also used First Aid and Lippincott for pictures and important pathways. When I was “done” studying biochemistry I went through every picture in Lippincott making sure I knew the pathways and diseases stressed. I did a lot of biochemistry because I could never remember the pathways. I can say, though, that studying for boards was the first time I really understood a great deal of biochemistry. That’s one of the nice things about studying for this exam; I was able to see things in a new light. With a year of practical knowledge under my belt, things like the glucose pathways and the inborn errors of metabolism just made more sense.

Physiology: I taught physiology and it was my strongest subject so I devoted too little time to it. Linda Costanzo writes most of the books on this subject for a reason. My favorite source is a physiology review (yellow and blue) book by her that I found in the library. It offered like 300 pages of really high-yield stuff for the boards, but required a good deal of knowledge to understand it. I loved this book, all 150 or so pages I read, and if physiology is a strength of yours, you might consider using this to build on that.

Immunology: First Aid and first-year text for diagrams of important things and the first section of the Pathophysiology of Human Disease text by Lange. This is a huge subject; I don’t have any idea what one should study for it but common immunodeficiency stuff is important, bigtime cytokines are important, anatomy of the lymph node and spleen were in a lot of resources, and basic relationships between B & T cells seemed important.

Micro: Micro Made Ridiculously Simple, used this for both micro and abx. Along with First Aid. I loved this book.

Neuro: High-Yield Neuroanatomy. I overstudied this segment by reading this book three times but it was very good and quite thorough.

Histology: Junquiera for pictures the day before the exam and on rare occasions as a pictorial representation of some concepts in other classes.

Behavioral Science: BRS Behavioral Science and Qbank two extra times. I read through this book like 3½ times, this took up more time than any other subject for me because I’m terrible at behavioral. BRS is pretty much regarded as the gold standard in behavioral science.

Path: BRS Pathology and Robbins Study Guide (question book) LOTS OF ATTENTION

Pharm: Katzung Review of Pharmacology. Great book. Even if you don’t like this book, the chapters in the beginning up to the end of sympathomimetics are absolutely worth your time.