by Ayaz Mahmood

Salam everyone, let me start in the name of Allah who’s the greatest benefactor of all mankind. I am going to write a detailed composition regarding preparation for USMLE Step 1. I am a final year student at King Edward Medical University and I took my exam on June 10th. Final year is the year before internship/ house job in Pakistan. I just got my scores: 99/266

Let me introduce some myths surrounding USMLE Step 1 which are especially prevalent within Pakistan; I am not too sure about India because I heard their students typically appear in their final years.

 Myth number 1:Do not appear for USMLE Step 1 within your graduation

Verdict: Baseless, illogical reasoning

Explanation: This is so prevalent in Pakistan it’s almost pathetic. One of the biggest concerns surrounding our students is that Step 1 is a huge risk to be taken before graduation. Let me put it in another way: Step1 would always remain a risk whenever it is taken, whether during or after graduation, whether with a preparation of 4 months or a preparation 14 months. It is an unpredictable exam. Let me reassure you that taking Step1 within your graduation would, 90% of times, result in a score that would be substantially higher than when having taken after your graduation. Why? It’s simple! You have a habit of studying for prolonged time periods and you haven’t yet stepped into your professional field. Furthermore what you have been studying all along during your medical studies is still fresh in your mind. Basic sciences is something that troubles even the experienced doctors, let alone a mere young student. It’s all about finding the right tempo to study for extended time and when you enter the profession, that is something quite troublesome. Take my advice: rather than wasting your time during your medical studies, spend it swimming through Step1 recommended textbooks.

Remember you are in direct competition with medical students of US. They typically appear for Step1 at the end of their 2nd year and Step2 at the end of their 4th year.

Myth number 2: You need clinical exposure to fully understand Step1’s clinical vignettes

Verdict: Not necessarily!

Explanation: Remember US medical students don’t have any clinical exposure leading up to their Step1 exam. While attending wards may help you understand the methodology leading to diagnosis and management, you definitely do not need to wait till you acquire maximal clinical experience for Step1. Most of the cases can be fully understood easily by simply applying knowledge of basic sciences you just learnt. Radiographs and gross specimens can be practiced by simply getting help from the world wide web and selected university department websites. Similarly heart sounds can be made available through a simple Google search. You just need to be active enough to utilize the internet as an aid to your studies. You would only be rarely tested for management of the patient, which is the primary focus of Step2 CK and not Step1. In majority of occasions, application of knowledge of basic sciences is what is expected of you.

Myth number 3: Cram, by heart, all of Kaplan series

Verdict: Wrong and time wasting!

Explanation: Let me begin by stating US medical students only rarely, if ever, turn to Kaplan for their study. At a later stage of this article, I would lay out the recommended books for you. Kaplan definitely is a good series but thinking that it lays out the syllabus content of Step1 for you is nonsense. Step1 does not have a very well defined syllabus. The closest you can get is finding the syllabus release on usmle.org for Step1. Instead of spending time cramming all of it, it’s more useful to concentrate on selected areas more. You can totally skip out its Physiology book and replace it with BRS Physiology. You can do the same to Pathology book and replace with Goljan. You’d need to supplement biostatistics with high yield biostatistics. A lot of information written in Kaplan is vague, especially the Genetics part of Biochemistry, and very rarely, if at all, tested. Some topics need more elaboration than what’s published: Cancer chemotherapy, Lysosomal storage diseases. Microbiology typically requires substantial usage of Levinson to fully master the bugs. At a later stage, as stated already, I would lay out the books you need to study for an efficient preparation.

Myth number 4: First read, Second read, third read, fourth read, Step1

Verdict: This depends!

Explanation: Remember everyone has his own way of studying. This sequential method typically follows the Kaplan series and has little significant benefit. It is very rigid and cannot be modified. A lot of people asked me repeatedly how many reads I have done. My answer was always the same: is the number of reads the method to use to judge someone’s preparation? That’s the purpose of NBME sample assessment. Don’t let the “number of reads” fool you. Some people study fast and they find that spending little time on everything gives them sufficient time to revise; others find the opposite to be true. This means a person who has done 2 reads may be doing just about as good as another who has done 7 reads. Besides some subjects need more reads than others; pharmacology needs more commitment than does anatomy.

Confused? I am too! When you try and follow “number of reads” rule, you’d end up even more confused. Solution? Try and find your own best method. If you get a good NBME score, this means you’re doing fine. For more info on NBME, read on.

Myth number 5: If you get less than a two digit score of 95, you’re good as gone.

Verdict: Ignorance!

Explanation: While Step1 is very important, it is not the only thing required to judge a candidate. Remember there’s Step2 CK as well, number of attempts at Step2 CS, Electives, Research experience etc. They all form part of what is known as a “well rounded candidate”. Not everyone gets a 99 at Step1 and those who don’t must not lose their confidence. Step1 is an exam, just like every other exam and is prone to causing mishaps and accidents in results. If that happens to you, I guess hard luck but should you lose hope? Go and read the first article written by Dr: Umar on hope! Try and compensate from Step 2 CK or the best of all, research. Don’t make Step1 a matter of life and death because it’s not worth it.

Myth number 6: Step 1 is all about concepts….

Verdict: and…..cramming!

Explanation: Don’t be fooled into thinking you don’t have anything to learn in Step1! Microbiology, Immunology and Pathology have far more knowledge that has to be learnt compared to what you do in college, in addition to making concepts. By all means, make maximal attempts as learning as much information as possible. If you don’t know the virus names and groups, you cannot answer any question based simply on “concepts”. Knowledge in Step1 is tested very rigorously, but it is typically very cleverly disguised as they simply form a part of the multiple process thinking. Learn everything; don’t leave things out. Yes and that means you have to learn Ebola virus, Japanese Encephalitis Virus and Lymphocytic Choriomeningitis Virus too!

Myth number 7: 70-80% of Step1 exam is full of Pathology

Verdict: Wrong!

Explanation: It’s true that almost 95% of the exam has clinical vignettes that can be directly correlated to Pathology however the subject matter that is being tested may not necessarily be pure Pathology. You may be given a vignette on Ataxia-Telengiectasia but you may be tested on an immunological concept, or a molecular biology concept. Now that the current USMLE exams are full of clinical vignettes (as stated on the official usmle.org; number of questions in clinical vignette forms to be increased), you would find this to be even more prevalent.

My purpose is to tell you to divide your attention equally amongst all subjects. 70-80% Pathology on exam never means 70-80% time on Pathology and 20-30% time on remaining subjects. Infact Molecular Biology is a dominant force. Step1 reflects current standards of medicine. You may infact realize that spending more time on Microbiology than Pathology would be more high yield.

Myth number 8: Delaying the exam by a month or two would increase my score

Verdict: What makes you think the opposite may not happen?

Explanation: Read the verdict again, and again and again. Do you have any guarantee that you would definitely not slack off, run the risk of forgetting important facts after breaking your study momentum and decrease your score instead? Remember momentum and sustained effort are extremely important. When you choose an exam date, stick to it. Try to carry your momentum straight uptil that date. Breaking your rhythm would only increase your anxiety and make you forget important facts.

Myth number 9: My friend got a lot of virology in his exam; I must spend all my time studying virology

Verdict: Fair enough, but isn't "all your time" a bit too ambitious?

Explanation: The issue here is that there is little uniformity within a Step 1 exam, and little comparative value between Step 1 exams in terms of subject content, NOT standardized 2 or 3 digit score. For example your friend just gave Step 1 about 2 weeks prior to your final date. He seemed to get a lot of questions from virology and defense mechanisms (behavioural sciences). Should that make you think you should spend your next 2 weeks till your final date studying with full force, these topics? This is a common psyche of anyone who is about to take his or her exam, to rely a lot on what has already appeared. It's fair enough, but you have to make sure you do not compromise the rest of your study. Step 1, as stated already, is an unpredictable exam. You may be tested a lot, instead of virology, on mycology on a disproportionately high scale i.e. far more questions than you might anticipate. When you go through Step 1 forums, you may see some people stating they got a lot of biochemistry but little anatomy, and others attesting to the exact opposite.

You should always make an effort to study each and every subject in Step 1 with equal time and honesty. As stated elsewhere, yes, there are subjects like Pharmacology and Microbiology that require disproportionately more time but this is not because they appear a lot on the exam, but because of the nature of these subjects that warrant consistent revisions.

If you can find any more myths, please discuss them in comments and I’d include them here.

Now let me talk about the recommended books for you.

BOOKS:

Get all of Kaplan series. You may omit Physiology totally. You may if you like, also omit Pathology. Buy the DVD lectures as well (remember the copies found in our country are illegal; if possible, they should be bought at kaplanmedical.com). Here’s a little run through the individual subjects:

Physiology:

All American students rely a lot on BRS Physiology. It’s a fantastic book that focuses on the most high yield content you need to know with all the necessary graphs. The problem with Kaplan is that it includes discussion of quite a few topics that are not tested on Step1 e.g. Vascular Physiology. These are also discussed in heavy details that entail a lot of time commitment. BRS Physiology has everything you need to know in Physiology plus an additional chapter on Neurophysiology which is not discussed even in Kaplan’s neuroanatomy.

Biochemistry:

Kaplan should suffice here. Infact Kaplan is a good book. Some topics need supplementation. You should consider studying lysosomal storage diseases from elsewhere; first aid has details of all lysosomal diseases. Listen to the lectures as well if you like. Dr. Lionel Raymon explains the concepts exceptionally well.

Molecular Biology:

Again Kaplan should suffice here. Some American students consider studying High Yield Molecular Biology. I got it and found it to contain a lot more information in excess of what’s required. Other American students think the 1999 version has just about enough info. But I don’t trust an old book. Sticking to Kaplan should suffice. Techniques should be referred from High Yield Molecular Biology as they are poorly explained in Kaplan.

Genetics:

The first three chapters are fine. Add another chapter from Genetics chapter of the Pathology book. The last three chapters are something of a lost sheep wandering aimlessly. I have never heard LOD scores being tested in Step1. Techniques of genetic analysis are very commonly tested but they haven’t explained it in a satisfactory way. This problem also arises in the techniques chapter of Molecular Biology section where irrelevant details hamper acquiring a good command of the actual subject. Studying these techniques from high yield molecular biology may be time consuming, but they are well explained and may help you get questions correct. Although technique methodology is not tested, knowing the techniques give you confidence in answering the question so study them in detail. Don’t underestimate this topic!

Anatomy:

Neuroanatomy is good enough. High yield neuroanatomy is also a good book; I heard some Americans studying it. I cannot recommend other texts as I don’t know them. Remember it is extremely important that you know the clinical scenarios very well, CT-scans, MRI’s, and gross specimen. In this manner, High yield is a very good book because it has many such illustrations and snaps. You should have a very good orientation of the brain in all planes: sagittal, coronal and transverse! Using help from university department websites can be of immense help. Search “webpath” on Google and navigate into the Pathology department of Utah University.

Histology is written in a way you’d forget as soon as you read. When you go through again, the same happens. Third time isn’t too lucky either. Here use High Yield Histology. At first glance this book seems to be a lot more detailed than needed. But that detail isn’t just histology. It’s the bridging knowledge and concepts that spans physiology, pharmacology, biochemistry and pathology! Try to find the original textbook as there are excellent illustrations and photographs at end of every chapter.

Gross Anatomy is fair enough. But you may need help from major texts such as Snell to study the Pelvic region which is disappointingly poorly explained in Kaplan.

Embryology is spread throughout Gross Anatomy. It’s useful enough. Basic embryology needs supplementation from other texts. I used a quick read through Langman’s embryology to get a hang of the initial development of the embryo. Most American students state First Aid embryology is good enough. You can trust that opinion. You may also use High Yield embryology. But you can just stick to First Aid here.

Behavioural Science:

When I first went through it, it looked out I didn’t go through it at all and only had a déjà vu that I did go through it. On a serious note, it’s a pathetic book. Even when supplemented by lectures, it doesn’t lose its pathetic appeal. You will have to use High Yield Biostatistics to simply understand just what the hell is going on around with all those lines and numbers and paranoid P-values.

Here’s how I learnt my behavioural sciences. I used to study the explanations to behavioural science questions in question banks. I used First Aid Q and A book. Explanations about respective questions were well written and I would write them in a notebook and go through them regularly (number of reads anyone, please?). Eventually I just got a hang of it all. The personality disorders, the defense mechanisms, DSM manual etc. Kaplan is jittered with useful info and you’d realize it once you study schizophrenia (cram all of Kaplan, everyone raise your hands!). I had BRS Behavioural science but I didn’t use it. I didn’t want to feel like an uncertified tester of all the books that are medical, just as I am of all the different web browsers (Safari is the worst of all).

Here’s a tip for you. Best way to learn behavioural science is to get a lot of questions incorrect in question resources, and then diligently study the explanations and promise by God you won’t underestimate this subject again. ONCE you have done that, now you can rely on Kaplan. The only thing reliable is medical ethics. Try and study the scenarios given in the two chapters. Some Americans suggest Medical Ethics by Conrad Fischer. I didn’t use it (I told you I don’t want to be a unpaid tester of books!). Unfortunately it seems that the American board examiners are extremely clever at finding just those special circumstances for you, where you’d eventually pick the wrong answer that happens to be both morally and legally incorrect, even though you thought the contrary!

Guess what, you can safely skip that mammoth table about human development in Kaplan and simply replace it with what’s written in First Aid. Everytime I looked at that table, I was more worried in counting how many milestones I achieved when I was a young boy rather than learning it. Not for a single time I had to repeatedly remind myself I did have a hint of object permanence at age 1 but then again………..what’s that?

Immunology:

Kaplan should suffice here. I didn’t use the videos because I thought my concepts were clear courtesy of Levinson. Strangely enough, the immune faculty was kind enough to write a continuous prose for us rather than shoot bullets (points). Remember again that immunology techniques, similar to genetic and molecular biology techniques, are very important and should be clearly understood and learnt. For example KNOW the difference between ELISA and Western Blot very well! Diseases are very frequently tested. When you supplement your study with First Aid Q and A book (Buy it!), immunology diseases would become progressively clear. Stay loyal to Kaplan here; you don’t have to spend too much time on other books. Actually I did use Levinson occasionally especially for diseases. It takes time but it’s a fantastic book written by a UCSF professor who is an authority in Microbiology and Immunology. At end of Kaplan, there is an appendix detailing CD markers. Learn it by heart.

Pharmacology:

Use Katzung Board Review series here. Surprised? I’m not. That is the best book. Again it is written by a group of three UCSF professors who know what’s needed for Step1. Some topics such as Chemotherapy and Anticancer drugs are so important you have to study them in detail. Katzung is more than enough detail and you can totally rely on it. Because Dr. Anthony Trevor is also a co-author of Kaplan’s Pharmacology, there are some similarities between the two which means once you go through Katzung, you can review Kaplan easily. You may consider annotating Kaplan with Katzung’s points. They test each and every drug, even Sitagliptin and Orlistat. Be careful studying Toxicology because it is important. You will have to study it from katzung to know what’s it all about. ANS and CVS drugs are definitely high yield.

It would help you writing some points on a notebook and repeatedly revising it. For example, write all adverse effects of all anticancer drugs and keep going through it. Eventually you’d start remembering that pulmonary fibrosis is a prominent side effect of bleomycin and busulfan, Nephrotoxicity is not an issue with Sirolimus and a combination of Didanosine and Zidovudine has a high incidence of neutropaenia.

Microbiology:

Here they go again. All of that written either in points form, or tables form. If you supplement it with lectures, it ends up becoming a complete mockery of those little bugs. The bugs had to emerge resistant to it and no wonder they’re doing it so well, both in real life and on our exams. It would seriously help you if you just go and buy Levinson and just go through it atleast once. Some Americans recommend “Made ridiculously simple” Microbiology and you may use it if you like to. I also went through High Yield Microbiology but it didn’t sustain my interest. Viruses need constant referencing with Levinson to simply learn what haemorrhagic fever exactly is and what exactly is hand-foot-mouth disease. Parasites are just sugarcoated in tables. Again, study from Levinson. You won’t get the slightest hang of it from Kaplan. Microbial genetics is written fair. Remember you have to learn the mechanisms of resistant to different drugs, for example the acetyltransferase against chloramphenicol. You have to also learn which are plasmid mediated and which are chromosomal mediated. Transposons, plasmids, lysogeny etc are all a fair game and must be understood.

The case scenarios given at the end of Kaplan are slightly confusing but they’re a fair game as well. You can actually replace them with similar scenarios and common causative agents written in Levinson.

Pathology:

Goljan appears to be the undisputed king here. You can also listen to Goljan lectures (remember their possession is illegal! I don’t know if they even officially release any lectures in first place). But you can quite comfortably rely on its 3rd edition that spans not only Pathology but also bridging concepts to Pharmacology, Biochemistry and Physiology which ensure active revision and repetition of these subjects. Some American students say they also relied on the side notes given in the book especially just a few days before the eventual exam and it was a massive help. This is a detailed book so make sure you allocate enough time. Make sure to buy the original version so that all the micrographs and gross specimens are clear.

Contrary to popular belief, Pathology doesn’t make 70-80% of your Step1 exam as already explained earlier in the Myths section. So don’t allocate time in excess of what’s required, that may compromise your study of other subjects.

But you can also study Kaplan’s Pathology. Because I was studying Pathology alongside my medical studies, I used Medium Robbins and annotated Kaplan’s Pathology with important topics. Make sure you fully understand that studying Robbins alone would result in low Step1 scores. Robbins overemphasizes topics that have little clinical value and understates the ones that are exceptionally high yield. Still you may atleast like to go through it once (only if you are studying for Step1 during medical studies) to get a grip on what Pathology is all about. Some students would suggest studying Big Robbins but again, you need to know studying what material is higher yield. Big Robbins is typically for students who have little else to do apart from studying. As you go through Kaplan, the point format may frustrate you so you may want to revert occasionally to Medium Robbins to study topics like Pneumoconiosis in detail before feeling confident about learning material from Kaplan.

Some people suggest BRS Pathology. I don’t know about that. It’s entirely up to your choice. Perhaps you may want to use its illustrations, photomicrographs and gross specimens for supplementary study. Be sure you also utilize Utah University Pathology Department’s Webpath website.

OTHER BOOKS

First Aid is a favourite amongst American medical students. I only went through it twice but I found it to be quite helpful. You may like to study it once early in your coursework and once later before the exam. You can even go one step further and make it your primary book. In that case you may have to annotate it and make up for the deficiencies in this book. In my opinion, it still has enough information to guarantee a 99 on Step1 provided you study it comprehensively and carefully.

Kaplan medessentials is a similar book to First Aid. It has essentially all of the Kaplan series condensed into a single book. Some Americans call it medsuperfluous. It’s unnecessarily detailed at some places and understated in others. Still it has the benefit of complementing your Kaplan textbook study. You may use it if you like a very quick glance at a lot of information, typically arranged system-wise e.g. Cardiovascular system. This helps you to save time flipping through different books in case you like to apply a systems approach at some point during your coursework.

Step1 secrets is another rather useful book I encountered. I didn’t study it all so I cannot comment but based on others’ opinions, it has everything arranged neatly in a question-and-answer format and written in simple language. Oversimplification is evident at a lot of places and requires rigorous supplementation by more detailed textbooks. If a high 99 is not your aim or if you realize that studying simple textbooks may ensure something like a 90-99 score rather than pursuit of a high 99 having to utilize detailed textbooks and running the risk of losing score, that’s the book for you. It has little of everything that should benefit you in the actual exam. If nothing else works or you have run into anxiety, throw every other book away even First Aid. Pick this book and just study it. It is written in a beautiful manner utilizing a very student friendly approach and doesn't run aggressively amok anywhere. Studying this book alone carefully can give you a 90+ score.

QUESTION RESOURCES:

You have the following question banks. They are discussed separately.

USMLE World:

It can be found at usmleworld.com. This question resource has consistently high ratings amongst students and Americans love using it to supplement their study of First Aid. You can buy it for 100$ for one month. Subscriptions greater than a month have substantial discounts. You can get their books but they’re all pirated and illegal material. I would highly recommend buying this for a single month at least. Typically this should be used to maximum effect about 1-2 months before your actual exam. Others recommend using it as soon as possible but I have a different opinion. The explanations given in this resource are the best amongst all others and some Americans actually solely rely upon the explanations for their revision. If you start it late in coursework, you ensure adequate revision and security of keeping it in memory. Questions typically use 2-3 step thinking processes and require good integration of concepts, so it’s a tough question resource. My advice is to solve all questions and read their explanation regardless of whether you get any question correct or incorrect.

KAPLAN Qbank:

This can be accessed at kaplanmedical.com. It is very expensive: 130$ per month and additional months purchased have substantial discounts. You can get their books but again, that’s pirated and illegal. They don’t release any textbooks. Americans don’t prefer using this resource. Kaplan Qbank relies quite extensively on knowledge given in their textbooks and at times, it feels they are exclusively focused on specific knowledge pointers in their questions, rather than good integration of concepts as done by usmleworld. Furthermore it has a habit of testing knowledge that is both Step1 irrelevant and not given in recommended textbooks (not even in their own textbooks!). Overall I would recommend this Qbank. It has the advantage of using Qtutorials (refer to their website), good media, good explanations and a huge question resource. You don’t have to attempt all of the questions given. It’s preferable to use this resource early in your coursework.

USMLErx:

This can be accessed at usmlerx.com. This is the least expensive of all qbanks with a single month subscription at 70$. Instead of Kaplan you may want to utilize this resource early in your coursework. This is the work of contributors of First Aid. So it heavily relies on info resource of First Aid. This can be an advantage if you are using First Aid as well. Repetition of facts in first aid ensures adequate retention in memory. However some questions may not correctly reflect the standard and format of current USMLE exams and rely somewhat on typical case scenario facts and explanations. In addition, a lot more questions directly test knowledge rather than careful integration of facts. Best utilized early in coursework.

First Aid Q & A book:

Similar to usmlerx. In fact they state questions are taken from usmlerx resource. It has 1000 questions, 650 organized systems wise and 350 organized into a full length exam with 7 blocks (remember current USMLE has only 322 questions in 7 blocks). I used this book late in my study but I recommend using it early. It may be a less expensive substitute to usmlerx questions resource as well. Explanations are good and have cross referencing to First Aid text which may help your revision. Remember this is an official First Aid release.

Mededia Qbank:

Surprised? Stay tuned for more updates in near future! I assure you this would be a very high quality Qbank with MCQs according to the new format of more clinical scenarios and quality better than all mentioned qbanks. I am working with Dr. Umar Tariq on it; it would be available online in a few months times and would be entirely free of cost so you may start using this questions resource early or late in your coursework depending upon your choice. 

If you are interested in authoring MCQs for this Qbank, kindly contact me at dr.ayazmk@yahoo.com or Dr. Umar Tariq and we would be happy to include you as a co-author/ contributor on submission of some high-quality MCQs and would mention your name on the main book cover. I am sure it would prove to be a big boost to your CV and provide help to your colleagues; the same reason I am doing it for.

The reason for its inception is to reflect the current trends in the USMLE Step 1 exam. Step1 is an ever-evolving exam; the examiners are very well aware of what guide-books and short-cuts students love using. As an example heart sounds that appeared in previous Step1 exams could typically be resolved by simply contemplating the question stem and not even listening to the sounds, as stated by some examinees! Now you must have a sound knowledge of heart sounds. If you are as unlucky as I was, you may get those varieties sometimes only cardiologists can decipher with a degree of confidence. Apart from that, the examiners know that many students rely heavily on First Aid. By no means you can't get a 99 by studying First Aid alone, but this is to tell you that the style keeps evolving in order to maintain a very high standard of this exam. Therefore we decided to make a brand new collection of questions resource that would adequately aid your Step 1 preparation.

Wikitestprep.org:

This is a spin-off of Wikipedia with about 800+ questions free of cost, contributed by various authors. Because there is little quality check and control over the type of questions, a lot more questions do not reflect the USMLE style than questions that do. Integration of concepts is rarely tested. Since it’s free, you may like to use it early in coursework but remember that some questions are factually incorrect, others are vague and their explanations may not reflect high yield material.

NBME exams:

These exams can be purchased at NBME website for about 45$ each and has 200 questions each arranged in 4 blocks. You may buy about 2 or 3 such exams, from a total of 7. It is very important to use atleast one exam early in coursework and another late in coursework to gauge your performance levels, strengths and weaknesses. In addition a projected 3 digit score is given to you at the end of your exam that is highly predictive of your actual USMLE Step 1 score. NBME’s are also not reflective of current USMLE style. Most questions are very easy making the marking very stringent and strict. But you have to use these exams to quantitate your performance levels. I recommend buying 3. Use one early, another in the middle and the last one late in your coursework to ensure adequate progression in your study.

USMLE World Self-Assessment forms:

They can be accessed at usmleworld.com and have a cost of 30$ each. They are two in number. When purchased together, they cost 50$ in total. They have the added advantage of allowing you to study questions you got incorrect or correct and read all explanations, over NBME which allows neither. Best used late in your coursework and you should attempt to study all the explanations. There are 192 questions in each exam.

Kaplan Qbook:

This is an official release of Kaplan Medical. I did go through it randomly at first. It has various blocks of 50 questions each organized in a subject-wise manner (not systems wise). Unfortunately various questions are again not reflective of current exam and are typically "easy". The most poorly composed section is, as expected, Behavioural sciences. Two blocks of 50 questions each of absolute madness. It follows the same philosophy of Kaplan's Qbank somewhat hinting more at retrieval of an examinee's memory rather than integration of concepts.  

GETTING STARTED WITH IT ALL:

You have the choice to study either during your medical studies or after your graduation. As I already explained earlier, studying during your medical school is substantially better than after your graduation. However USMLE is a difficult exam that needs honesty and time commitment. You cannot study this exam for the fun or sake of it because that may seriously backfire with a very low score. Only sit this exam once you are sure of your preparation. Using NBMEs is one way of assessing your preparedness. In case you wished to appear in Step 1 during your medical studies but became very anxious or your NBME score is not so good, your time wasn’t lost! You can carry that knowledge over to studying for Step2 CK as well during your final year. In that case you may begin to feel confident enough to give Step2 Ck before your Step1 because you had already had some feel of how Step1 looks like.

The best way is to begin as early as possible in your medical studies. Study only good American textbooks. I recommend you to study the following textbooks during your medical education:

Snell’s Anatomy

Snell’s Neuroanatomy

Ganong’s Physiology

Lippincott Biochemistry and Molecular Biology

Katzung’s Pharmacology (Board Review Series)

Levinson’s Microbiology and Immunology

Medium Robbins supplemented by Goljan, or even Goljan alone

For behavioural science, you may have to rely on textbooks already stated above.

The textbooks above ensure you get a sound grasp on the subject in question. Using these resources ensure you’re automatically geared towards Step1 prep. Strictly avoid using textbooks authored in the subcontinent as not one single such textbook lives up to the standard of the books above.

Here’s a tour through a Step1 preparation.

First few months; getting started:

A lot of us subcontinent people use Kaplan. Americans get about 2 months off at end of their 2nd year, and study Goljan, First Aid and Usmleworld.

You may need to use the videos. You don’t necessarily have to listen to all these videos. You may form good concepts but as soon as that happens, you’d immediately forget later on. Using videos for referencing again and again is time consuming and frustrating. A good detailed textbook is a very good substitute. If grasping DNA synthesis from Kaplan’s biochemistry textbook is difficult, jump straight to Lippincott. Unfortunately this cross referencing is something you’d have to do extensively throughout your Step1 study. So keep all the major textbooks readied.

First just go through the Kaplan. Understand, learn or not, is not a matter. Try to get a feel of what Step1 syllabus content is like. Next you may want to use video lectures to aid you in understanding difficult concepts and also for the sake of simply touring through the Step1. In these first few months, use your major textbooks extensively. Don’t be afraid to open Snell’s neuroanatomy or Ganong’s Physiology to clarify difficult concepts. Once done, write them for your records somewhere. You can maintain a notebook to serve that purpose. Alternatively you may annotate the Kaplan books. Choice is yours.

Doing all of that would take quite a lot of time. Be patient. Don’t rush through your study schedule or try jumping ahead. Do justice to all your subjects. Remember subjects like Pharmacology and Microbiology require constant attention. This means that as soon as you’re done with your first pass, try to immediately jump back to these subjects and revise them. Don’t limit these subjects to a mere 3 or 4 reads. It’s indefinitely high yield to do as many quick reads of these subjects as is possible. This ensures adequate retention of facts in your memory. You don’t have to use question resources at this moment.

So the initial stage of your study is simply quick pass through the syllabus content + careful pass through selected and difficult topics with extensive cross referencing from major textbooks and maintenance of important pointers in a notebook. Don’t try to be a copycat and emulate others’ timetables. Find the right solution to studying yourself.

Intermediate stage:

This stage introduces the question resources. As already stated, you can rely on Usmlerx or Kaplan Qbank. Although you can find illegally printed textbooks to these question resources, they don’t give you the advantage of mixing your questions, making random timed or self-paced blocks and maintain a record of used and unused questions. As soon as MedEdia releases its questions resources free of cost, you may like to check it out as well.

My recommendation would be to use either question resource, and try attempting questions systems wise. If you just finished a revision of Biochemistry, hit the questions. Read the explanations to all questions, pick up a notebook and write the important facts in that. Go through those facts at regular stages. This would especially help you, in Biochemistry’s case, learn all the rate limiting enzymes and hormonal and allosteric controls. Allosteric controls form an important testing component and is especially tricky to understand, especially in the whole context of all metabolic pathways.

Use this approach and apply to all subjects. You don’t have to attempt the whole question resource, but make sure you do attempt atleast a sufficient number of questions. At this stage you may use either timed or self-paced mode.

At the end, try and attempt an NBME exam. This should give you an idea where you land and how far are you from your goal. Depending upon your goal and the difference from your goal, you can modify that final stage of your preparation in whatever manner you like.

Final stage:

Once again, quickly hit Pharmacology, Microbiology and especially Behavioural science and revise these subjects. At least go through remaining subjects once but the aforementioned ones should be given special attention to because of the ease with which they are forgotten. Remember now your momentum is very important. If you remain consistent in this stage, you would drastically improve your final score. If you take breaks or delay your exam, you would only end up wasting time.

Now is the time to start usmleworld.com’s question resource. Americans at this stage do 2 blocks of 48 questions (46 in real exam) everyday and spend time reading all explanations. They supplement those explanations into First Aid. You can try doing that too, to good effect. Mix in another NBME and/or Usmle world Self Assessment forms which have already been referenced to above.

Here’s an important point: IF your NBME score is far off from your goal, NOW you may contemplate delaying your exam. Always aim for the very high, but you have to have a realistic appraisal of your own intellect and ability. You must have both a very high goal, and a very realistic goal. It’s only you who can tell you what your abilities are. NBMEs usually are a very accurate gauge of your performance. What they state is approximately what your abilities are.

Keep using First Aid also, especially towards the week leading up to your eventual exam. Make sure you have been following CTs, MRIs, photomicrographs, gross specimens and X-Rays all along because these are heavily tested. Keep focused on learning heart sounds as well. Last but definitely not least, all those notes you made into your notebook, using your own familiar handwriting towards the end of your preparation would most likely keep your anxiety levels in check. Do not even think about opening a new book at this stage.

When you’re done with your Kaplan, throw those books away and concentrate only on First Aid and your own notes from Kaplan and question resource explanations in last two weeks.

In your final day, you may take a day off after a stressful spell that spanned several months. Make a list of things you need to take. Check your permit, Prometric appointment, passport and National ID card.

Some tips about what to do during your last day and exam day:

I had the biggest misfortune of totally screwing up my sleep the very last day. It wasn’t anxiety. It happens sometimes to me that I can’t go to sleep even after 4-5 hours and by chance, it happened the very last night too. Eventually I took a pill of Bromazepam, slept for 4 hours, and went to the exam. The whole day was a battle with drowsiness. Energy drinks did some trick but really, my first and second blocks were almost sacrificed which must have led to reduction in my eventual score.

I would advise you to take a sleeping pill the last night and ensure a good night’s sleep. This is critically important before your exam that drowsiness doesn’t take over. You can use energy drinks during the day of your exam but make sure you have used them before to be sure they don’t end up causing diarrhoea instead during the exam.

My experience with Step 1 preparation:

I started at the beginning of my fourth year. I was confident because I had the fortune of having studied good textbooks in preference to local ones. I started as usual: Buy Kaplan textbooks and the Video lectures. But I didn't use all the video lectures because quarter-way through I realized that although they are helping me solidify my concepts, they are of little value in revision. I listened to Dr. Lionel Raymon's biochemistry lectures, Dr. Anthony Trevor's Pharmacology lectures, and Dr. James' Neuroanatomy lectures. I may have listened to others too somewhat, but I don't clearly remember. All these mentioned lectures were the works of genius people indeed and by all means, you should listen to what they have to say about their subjects. You may elect to skip the other lectures.

As I have stated in the ideal preparation above, cross-referencing to good textbooks is important and I felt the need always to do that. From February through June, I managed to cover some subjects atleast once (Pharmacology, Biochemistry, Anatomy), others twice (Microbiology), still others only less than half (Immunology, Pathology) and remaining none (Physiology, Behavioural sciences). You can try this same methodology with the exception of including Behavioural sciences in the "twice" category with Microbiology. So much for a "first read" I guess?

In July I managed to cover some major portions of usmleworld questions resource especially microbiology and pharmacology. This helped strengthen my knowledge of these subjects. Later I finished my first pass through Physiology and Behavioural science (I told you I developed a deja vu right after studying this!).

I would cover Pathology text with my medical studies in fourth year. For example, when they had a class test, I'd study Goljan and Medium Robbins. 

Time passed and I started wasting time too. Perhaps I realized that attempting the Step1 at end of my fourth year was overly ambitious. It would have been very realistic if I started in 3rd year, which is why if you are a student in 3rd year, by all means start your exam preparation! Till November I had managed another pass at least once through most subjects, with the exception of Physiology and Behavioural sciences (yet again). In November I picked up First Aid and went through it in 2 weeks. I registered for NBME form 3. I attempted it on November.....27th I think (right after that was Eid-ul-Azha day). My score was projected 244. I realized that this was very decent, given that I had yet to seriously cover behavioural sciences and Physiology also.

After that, time for my professional exams at end of fourth year arrived. ENT, Eye, Community Medicine and Special Pathology were the subjects and I somehow managed a third position and distinction in Pathology. The latter was significant because it motivated me once again for Step 1. But this exam had seriously upset my rhythm and because my first ward in final year was a maternity duty (day and night for 2 weeks = no time for Step 1 prep), I lost my way. This was why I stated how important is your study momentum when taking into the final date. I somehow managed to pick myself up, had to spend substantial time applying for electives and finally started seriously in April. I finalized my date for June 10th, and immediately started covering Physiology and Behavioural sciences which I had neglected (and I'd advise you to not do as I did).

In that time I also went through Katzung board review pharmacology and some part of Levinson, especially Parasitology. I also immediately revised all of Pathology which I hadn't touched ever since I gave my fourth year exam. All of a sudden it turned into a hi-octane study mode. Cursing myself for wasting time, I gradually navigated my way through immediate revisions, and then picked up First Aid Q and A book. I attempted all 1000 questions and wrote a majority of explanations in my notebook. Afterwards I went through that once, especially revising the behavioural science explanations. This really helped me immensely. Now it was already May 12th. I picked up first aid and finished it in next 8 days. I had attempted Usmle world self-assessment form 1 on May 18th and my projected score was 256. Needless to say, I felt more relieved than happy that the break in my tempo didn't destroy my hopes. Then I picked up usmleworld once again and navigated my way through it studying the majority of explanations, and combining with the very final quick revision of kaplan series. This continued on into June.

On June 5th, I attempted the second usmle world self assessment form online. My projected score was 265+. Usmleworld doesn't give a score beyond 265 so it states it as 265+ instead. I was happy. In the final few days I went through explanations to the exam questions I just gave and my own notebook. I'd occasionally open a few books but I would advise you against it, to guard against unnecessary anxiety induction. Then the final day came, I arranged my things together: Passport, permit, ID etc, went and bought snacks, a sandwich, and energy drinks. At 9:30 PM I went to bed. I thought I fell asleep at 10PM only to wake up moments later. Sleeplessness continued till late night at 3AM when I finally took Bromazepam and went to sleep for good. But the damage was done, and damage continued into the first block of my exam. Second block suffered as well but after that, through sheer willpower I fought with my drowsiness and the exam and eventually finished it.

Moral of the story? A good night's sleep before your exam!

The exam really was very much like what usmle.org described it as. 46 questions per block, framed into clinical vignettes more so than not so. At some stages I felt that questions were unnecessarily stretched with clinical information. Exam has increased in difficulty overall, and timing did become an issue for me especially in the first block where I had to resort to guesswork towards the end but this was more attributable to my sleep problems rather than the exam itself. The new Mededia Qbank is designed to, therefore, reflect this trend and style. I will not write what topics were tested or what was the distribution of subjects and I strictly advise you not to do that either. The repercussions include ban from taking USMLE exam for a limited number of years! So don't disseminate exam information anywhere, even under the veil of anonymity internet provides you!

Word of special thanks:

First of all, all thanks to God. Second to parents.

The journey started when Dr. Umar Tariq explained to me how getting started with Step1 might bring some good fortune. That happened at the very start of my fourth year. I thought this sounded too cool. Then I got started on it. Who knows I might not even have started if he didn’t tell me to? True words of inspiration. The first person who stated the true words of guidance that was honest and sincere. The only senior at that time who encouraged me to gear up for Step1 and now I am happy to carry out that legacy.

Going through the preparation, I got in contact with another senior Dr. Mustafa Mumtaz. He also encouraged me to give it as soon as possible. His contribution was really important for me because he introduced the NBME concept to me and explained how it helps in measuring up the candidate potential. He also gave me many other tips about the exam for which I am very thankful. I would also like to carry that legacy and guide the juniors just like that, in a positive and encouraging way, the same way he did to me.

My brother, Dr. Ather (not a medical doctor; PhD), also had contribution in keeping me motivated about my eventual goal. Later I also got in contact with Dr. Hassan Aziz and Dr. Sultan Mahmood which helped me carry over my preparation.

If you are lucky enough to get seniors and friends like these, no one can bet against you going 270+ in Step1. Good luck in the pursuit of your ambitions.

If you have any comments that you want added to this article, please write them in the comments below.

Regards,

Ayaz