Stuff you might like to know about the USMLE Step 1

This summer I spent my vacation studying full-time for a humongous test called USMLE Step 1. I’ve already been contacted by a few of people with questions about this, so I thought I’d post something about it here for those who are interested.

What is the USMLE? 

It stands for United States Medical Licensing Exam. This is a board exam for medical students who wish to apply for residency in the US after med school. There are three (although really, four) parts.

Step 1 is the first exam you will take, commonly after fourth year (if you are in a 6-year medical program like at the Medical University of Gdansk). It can be taken later, but if you want to spread out your exams and finish the required ones in time to start residency immediately after graduation, then typically students take Step 1 after fourth year.

Step 2 consists of two parts: Step 2 Cs which is a simulation of clinical interactions with patients (actors who are evaluating your bedside manner). Step 2 Ck which is another theoretical exam based on clinical knowledge. Step 1 and 2 need to be taken before applying for residency.

Step 3 can be taken before or during residency. However, I have been advised by a current resident that it may be easier to take Step 3 before residency (understandably, as it seems quite busy to study for an exam while you’re working long hours at the hospital).

What do I need to know for Step 1?

Step 1 is the biggest and hardest of the steps, according to anecdotal evidence (ie, I’ve heard this from residents in an American hospital). This 8-hour exam consists of 280 multiple choice questions. It covers material from everything you’ve learned in medical school so far: anatomy, embryology, physiology, biochemistry, microbiology, pharmacology, pathology, and clinical presentations of internal diseases.

A note for my colleagues at the Medical University of Gdansk: With the revised curriculum, I noticed that the exam covered some topics which we had not yet covered in fourth year. This didn’t pose any major problems, it just meant I needed to do some self-teaching. I’ll be extra prepared for those courses when they do come up at school!

Do I need to take the USMLE? 

This exam is for students who:

-want to work as a doctor in the US

-want to specialize as a doctor in the US and then move to Canada to work. This is a common route to consider for Canadian med students who study abroad.

Note that if you want to go directly to residency in Canada, you will need to take another set of board exams called MCCQE and MCCEE.

Where do I even begin? For GUMed students: 

If you are in first year, second year, or third year in our 6-year program, take a deep breath and relax! You don’t need to worry about this until fourth year, in my opinion. Just being aware of this exam for now will be enough so that you are prepared to take the appropriate steps later. Some prep books recommend studying USMLE material throughout the earlier years,  but I think this is more relevant to students in an American medical school. From my experience at GUMed, there is enough material to study and learn for our courses. You should focus on passing and doing well on school exams first.

When you are in fourth year, you will be allowed to register for two important elective courses– one is mandatory (USMLE mock exam) and one is optional (which I shall refer to as the USMLE prep course). Important! This may change, so check with the professor to confirm updated rules!

In order to be allowed register for your USMLE exam date, you must first pass the USMLE mock exam held by GUMed in the elective course. You will be given access to a question bank for practice; those same questions will appear in your mock exam. I found that practicing and memorizing as many questions as possible was my best strategy for passing this exam. Granted, there are thousands of questions, but I found that for the sake of passing the mock exam, learning from the question bank was most effective.

I did not take the optional prep course. Knowing my own learning style, I learn best when I sit at home and teach myself, even after a teacher has said it in the classroom. I decided that my time was best spent by sticking to a self-study schedule. This worked for me because self-discipline is one of my strengths; if you are someone who requires external deadlines for motivation, you may want to consider signing up for this weekly prep course.

Meanwhile, throughout fourth year, I started studying the First Aid book (see below). I read the psychiatry chapter during the psychiatry course, the nephrology chapter during nephrology, et cetera. I also read some of the chapters I knew would be challenging for me, in order to get a bit of a head-start on those before the summer. My goal was to read all the chapters once before summer, although I had to modify that goal slightly as school exams and the mock USMLE became more demanding.

By the way, you will have a great deal of paperwork and online forms to take care of before the end of the academic year. You can start looking into that as early as October. I will admit that the bureaucratic process was a bit confusing and a bit of a blur, so I couldn’t tell you exactly the steps you have to take. I will refer you to google search “ECFMG OASIS,” and take a look in the First Aid introductory chapter.

Which resources should I use to study for USMLE Step 1? 

This is the part where I can only give a recount of my own experience, which means the same may not apply to you! Keep in mind that everyone learns differently and there is no single strategy proven to work for everyone.

  1. First Aid for the USMLE Step 1. This textbook is what we may call the “bible” of USMLE Step 1. Everyone I know who has taken this exam says this is The Book to use. I was advised to buy the latest version to make sure I have updated tips on which topics are high-yield.
  2. UWorld Question Bank. This was an excellent resource which I strongly recommend getting as early as possible. I subscribed to both the “self assessment” and the “Qbank.”The “self-assessment” consists of two simulation exams which give you an approximation of the 3-digit score you may receive if it was the real exam. I’ve heard that these predicted scores are relatively accurate, sometimes a bit lower than your true score. I took the first simulation exam at the very beginning of the summer, to help me evaluate my strengths and weaknesses. I took the second simulation exam one week before my scheduled exam date, as a final confirmation I was on the right track. This still would have allowed me enough time to re-schedule my exam if the score showed I was not ready. Fortunately, I was indeed ready! I am happy with my score (and even happier that it’s done)!

    The Qbank of practice questions is a great resource not just for continually testing yourself, but also for learning. I found that reading the answer key was really helpful to learn why the right answer was right, and also why the wrong answer was wrong (a very important skill for multiple choice exams).

    Another important benefit from using UWorld throughout your studying is that the layout of their questions is nearly identical to the format of the true USMLE. By the time I sat down for my real exam, I felt comforted by the familiarity of the exam program. This made it much easier to focus on the content of the questions!

    Click here to link to UWorld

  3. Pathoma videos. In my opinion, the above two resources were mostly sufficient. I had already studied all the Pathoma videos at least once during the third-year pathomorphology course, so I was familiar with the material. I didn’t spend too much time on the videos. Instead, I used them occasionally as an extra resource. I turned to them especially during my last review weeks, when I wanted a concise summary of the material right before the exam.

How much do I need to study for Step 1? 

The only real answer to this question is: It depends.

It depends on how much you learned during your studies so far, how high you want to score, which specialization you want to apply for, how quickly you learn, and so on. As a general idea, most GUMed students I have talked to started reading First Aid throughout fourth year, then study hard during the summer, and plan to take Step 1 at the end of the summer.

How do I start studying? 

Anyone who knows me will know that I am a planner. Thus, it can only be expected that my subjective advice is to start out by making a plan!

On my first day of “real” studying at the beginning of the summer, I sat down for a few hours and mapped out my study schedule for the next few months. This is the most beautiful plan I have ever made because, importantly, it proved to be realistic and effective. I realize that not everyone likes or needs to plan their time so precisely. However, I do believe that it is important to have at least a brief timeline to serve as a reference to see if you are on track. My goal was to learn as much as I could by working hard, but also not too hard so as to avoid getting burnt out.

For those seeking organizational inspiration, here’s how I approached making a study plan:

  • I made a list of all the chapters in the First Aid book which I needed to cover.
  • I ranked them from weakest to strongest; I wanted to start with my weaker subjects  because later in the summer when I was tired, it would be easier to study my favourite topics.
  • I looked at my calendar and counted my number of weeks before my target exam date, taking into account some time off for travel and jet lag, and a couple weeks at the end for a final review of important material.
  • I assigned one or two chapters per week.
  • Every week, I broke down my days from Monday to Sunday, and divided up my total reading and practice questions into daily goals. My weekly cutoff was Sunday night; regardless of what I had or had not completed by that time, on Monday morning it was time to move on to the next topic. This deadline helped me cram in small doses throughout the summer, saving me from a last minute frenzy.
  • Remember to schedule in regular rest-days!

I am privileged to have been able to commit myself to my plan, that I had few external responsibilities or distractions apart from studying. I am grateful to the people around me who helped make that possible!

What was the exam like? 

It was pretty much what I expected. The level of difficulty was quite similar to UWorld, in my opinion. If anything, some of the questions may have been more straightforward and easy to understand on the real exam. You are permitted to take a break after every hour-long block of questions, which I did. There were a lot of security measures as you enter and exit the exam room, though, so keep in mind that you will lose several minutes of your break time for fingerprint scanning and such things.

I am glad I brought lots of snacks and a thermos of coffee. I am also glad I dressed in lots of layers, as the air conditioning was pretty chilly in the exam room. You will have to bring photo ID (like a passport) and your Scheduling Permit. ABOVE ALL, REMEMBER TO BRING THAT STUPID PIECE OF PAPER!

The Scheduling Permit is something you will receive in an email after you have booked your test date. It is absolutely mandatory to present this piece of paper to be allowed to write your exam. I printed two copies (one in pocket, one in backpack), and also saved the PDF on my phone. During one of my breaks I overheard a girl experiencing the worst nightmare– she didn’t even know which piece of paper the examiners were talking about, let alone bring it with her. Imagine working so hard and building up all the anticipation for that big test day, only to be told you aren’t allowed to take the exam… BRING THAT PIECE OF PAPER!

The hardest part of the actual exam day is staying awake and focused until the very end. 7 hours of questions with only 1 hour total break time is not easy! Those last couple hours were a battle to keep my eyes open. I was saved by coffee, and the knowledge that it would soon be over!

I would like to wish you all the best in your USMLE endeavours! It takes a lot of hard work, but in the end it’s not as scary as it may seem. You’ll be fine. Good luck!