USMLE Step 1 Experience In Final Year Pakistan by Mazhar Khan (Score : 252, Alhamdulilah)
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 Final year student at Chandka medical college Larkana and I took my exam on Feb 13th 2019. Final year is the year before internship/house job in Pakistan. I just got my score: 252, Alhamdulilah
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. So, here are my USMLE Step 1 Experience In Final Year Pakistan.
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: Step 1 would always remain a risk whenever it is taken, whether during or after graduation, whether a preparation of 4 months or a preparation 14 months. It is an unpredictable exam. Let me reassure you that taking Step 1 within your graduation would, 90% of time, 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 have not 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 trouble 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 Step 1 recommended textbooks.
Remember you are in direct competition with medical students of US. They typically appear for Step 1 at the end of their 2nd year and Step 2 at the end of their 4th year.
Myth number 2: You need clinical exposure to fully understand Step 1 clinical vignettes
Verdict: Not necessarily!
Explanation: Remember US medical students don’t have any clinical exposure leading up to their Step 1 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 step 1. Most of the cases can be fully understood easily by simply applying knowledge of basic sciences you just learned. Radio-graphs 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 Step 2 CK and not Step 1 . In, majority of occasions, application of knowledge of basic sciences is what is expected of you.
Myth number 3: Cram, by heart, all 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 step 1 for you is nonsense. Step 1 does not have a very well defined syllabus. The closest you can get is finding the syllabus release on ‘usmle.org’ for Step 1. Instead of spending time cramming all of it, it`s more useful to concentrate on selected areas more. 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
Verdict: This depends!
Explanation: Remember everyone has his own way of studying. This sequential method typically follow the Kaplan series and has little significant benefit. It is very rigid and can not 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 mean 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 mean you are doing fine. For more info on NBME, read on.
Myth number 5: Step 1 is all about concepts….
Verdict: and ….. Cramming!
Explanation: Don’t be fooled into thinking you don’t have anything to learn in Step 1! Microbiology, Immunology and pathology have far more knowledge that has to be learned compared to what you do in college, in addition to making concepts. By all means, make maximal attempts as learning as much information is possible. If you don’t know the virus names and groups, you cannot answer any question based simply on “concepts”. Knowledge in Step 1 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 not leave things out. Yes and That means you have to learn Ebola virus, Japanese Encephalitis virus and Lymhpocytic Choriomeningitis Virus too!
Myth number 6: 70-80% of Step 1 exam is full of pathology
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 concepts, or a molecular biological concept. Now that the current USMLE exam are full of clinical vignettes (as stated on the official usmle.org “number of questions in clinical vignettes form 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
Myth number 7: 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 until that date. Breaking your rhythm would only increase your anxiety and make you forget important facts.
Myth number 8: 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 subjects 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 question from virology and defense mechanisms (behavioral 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 other attesting to the exact opposite.
You should always make an effort to study each and every subject in step 1 with equal time and honestly. 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.
All American students rely a lot on BRS physiology. It’s 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 Step 1 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 neuroanantomy
Biochemistry & Molecular Biology
Kaplan should suffice here. In fact, Kaplan is a good book. Listen to the lectures ( Dr. Sam turco) explains the concepts exceptionally well.
Kaplan neuroanatomy lecture notes and videos (by Dr White) are very important. High yield neuroanatomy is also a good book ; I heard some Americans studying it. 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 illustration 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.
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.
Emberyology is spread throught Gross anatomy. But you can just stick to Firsd Aid here.
Kaplan should suffice here, strangely enough, the immune faculty was kind enough to write a continuous prose for us rather than shoot bullets (points). Remember again that immunology techinques, similar to genetics 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! Disease are very frequently tested. At last stay loyal to kaplan here; you do not have to spend too much time on other books.
Kaplan should suffice here, at last stay loyal to sketchy, and FA.
Use Katzung Board review series here. Surprised? I`m not. That is the best book. Some topics such as Chemotherapy and anticancer drugs are so important you have to study them in detail. Katzung is more than enough details and you can totally rely on it. Because Dr. Anthony Trevor is also a co- author of Kaplan pharmacology, there are some similarities between the two which mean once you go through katzung, you can review kaplan easily. You may consider annotating kaplan with Katzung points. They test each and every drug, even Sitagliptin and Orlistat. Be careful studying Toxicology because it is important.
It would help you writing some points on a note book 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 neutropenia.
When I first went through it, it looked out I didn’t go through it at all and only had a kaplan that I did go throgh it. You will have to use High Yield Biostatics to simply understand just what the hell is going on around with all those lines and numbers and paranoid P-values.
Goljan appears to be the undisputed king here. You can also listen to Goljan audio lectures. Some American students say they also relied on the side notes given in the book especially just a few day before the eventual exam and it was a massive help. This is a detailed book so make sure you allocate enough time, otherwise PATHOMA suffice here. Contrary to popular belief, pathology does not make 70-80% of your step 1 exam as already explained earlier in the Myth section. So do not allocate time in excess of whats required, that may compromise your study of other subjects.
You have the following question banks. They are discussed separately.
USMLE World (UW)
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 249$ for one month. Subscriptions greater than a month have substantial discounts. You can get their books but they are all pirated and illegal material. I would highly recommended buying this for a 3 months at least. Typically this should be used to maximum effect about 3-4 months before your actual exam. Question typically use 2-3 step thinking process and require good integration of concepts, so it’s tough question resource. My advise is to solve all question and read their explanation regardless of wheather you get any question correct or incorrect.
This can be accessed at usmlerx.com. This is the least expensive of all Q banks with a single month subscription at 89$. Instead of kaplan you may want to utilize this resource early in your course work. This is the work of contributor of First Aid. So it heavily relies on info resource of First Aid. This can be an advantage if you are using First Aid as well. Repetition of facts in First aid ensure adequate retention in memory. However some question may not correctly reflect the standard and format of current USMLE exam and rely somewhat on typical case scenario facts and explanations. In addition, a lot more question directly test knowledge rather than careful integration of facts. Best utilized early in coursework.
This can be accessed at kaplanmedical.com. It`s very expensive: You can get their books but again, that’s pirated and illegal. They do not release any textbooks. American do not prefer using this resource. Kaplan Qbank relies quite extensively on knowledge given in their text books and at time, it feel they are exclusively focused on specific knowledge pointer in their question, rather than good integration of concepts as done by usmleworld. Furthermore it has a habit of testing knowledge that is both step 1 irrelevant and not given in recommended textbooks (not even in their own textbooks!) . Overall I would not recommend this Qbank.
These exams can be purchased at NBME website for about 60$ each and has 200 questions each arranged in 4 blocks. You may buy about 2 or 3 such exam, from a total of 6. It is very important to use at least one exam early in coursework and another late in coursework to gauge your performance levels, strengths and weakness. In addition a projected 3 digit score is given to you at the end of you exam that is highly predictive of your actual USMLE step 1 score. NBME`s are also not reflective of current USMLE style. Most question are very easy making the marking very stringent and strict. But you have to use these exam to analyse 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 40$ each. They are two in number. When purchased together, they cost 70$ in total. They have the added advantages of allowing you to study question you got incorrect or correct and read all explanation, over NBME which allow neither. Best used late in your coursework and you should attempt to study all the explanations. There are 160 questions in each exam.
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 medical school is substantially better than after your graduation. However USMLE is a difficult exam that need honesty and time commitment. You can not 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 NBME 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 was not lost! You can carry that knowledge over to studying for step 2 CK as well during your final year. In that case you may begin to feel confident enough to give Step 2 CK before your step 1 because you had already had some feel of how step 1 looks like.
First few months ; getting started :
A lot of us subcontinent people use kaplan. Americans get about 2 months off at end of 2nd year, and study First Aid, UW.
You may need to use the videos. You do not 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 biochemistry textbook is difficult, jump straight to lippincott. Unfortunately this cross referencing is something you’d have to do extensively throughout your step 1 study.
First just go through the kaplan. Understand , learn or not , is not a matter. Try to get a feel of what step 1 syllabus content is like. Next you may want to use video lecture to aid you in understanding difficult concepts and also for the sake of simply touring through the step 1. In these first few months, use your textbooks extensively. Don’t be afraid to open Snell’s anatomy or Ganong’s Physiology to clarify difficult concepts.
Doing all of that you would take quite a lot of time. Be patient. Do not rush through your study scheduler 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 immediate jump back to these subjects and revise them. Do not limit these subjects to a mere 3 or 4 reads. It is indefinitely high yield to do as many quick reads of these subjects as is possible. This ensure adequate retention of facts in your memory. You do not have to use question resources at this moment.
So 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. Do not 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 UW, Usmlerx, or kaplan Qbank. Although you can find illegaly printed textbooks to these question resource, 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.
My recommendation would be to use UW, and trying attempting questions system-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. These would especially help you, in Biochemistry cases, learn all yhe rate limiting enzyme and hormonal and allosteric controls. Allosteric control 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 at least a sufficient number of questions. At this stage you may use either timed or self-paced mode.
At the end, try and attempt 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 :
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 second round. American at this stage do 2 blocks 40 questions everyday and spend time reading all explanation. Mix in another NBME and/or UWSA 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. NBME`s usually are a very accurate gauge of your performance. What they state is approximately what your abilities are.
Keep your 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. Do not even think about opening a new book at this stage.
When you are done with your kaplan, throw those books away and concentrate only on First Aid and your own UW notes in last two weeks.
In your final day, you may take a day off after a stressfull 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 was not Anxiety. It happens sometimes to me that I can’t go to sleep even after 4-5 hrs and by chance, it happened the very last night too. Eventually I took a pill of Alprazolam 1 mg, slept for 4 hrs , 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 pills the last night and ensure a good night 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 diarrhae instead during the exam.
My experience with Step 1 preparation:
when I got admission in medical school, I was very happy, suddenly military operation ( Operation Zarb-e-Azab ) started in my district North Waziristan. Due to this military operation we suffered a lot economicaly, socially, and a lot of blood shed of people. Regarding this military operation it is worth mention that we displaced internally and start living in refugees camp. Because of all this serious concerns, I was tortured very much mentally even though that I failed first 2 years of my medical school exams, and was a big challenge for to face all these situations.
Aim of these little story?
If I can do it, you can do it too.
How I Started?
First 3 months: Jan 2018-March 2018
I started at the beginning of my Fourth year. I started as usual : kaplan textbooks and videos lectures. But I did not use all the videos 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 Pharmacology lectures, Dr. Turco`s Biochemistry lectures, and Dr. White`s Neuroanatomy lectures. I may have listened to other too somewhat , but I do not clearly remember. All these mentioned lectures were the work 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.
April 1, 2018- 15 May 2018 :
I covered all the kaplan series upto 30 march, then I started FIRST AID at 1st April and finished it upto 15 may, I.e in 1.5 months.
15 may 2018-15 Aug 2018 :
When I covered FA, then I bought UW subscription of 6 months , I covered it in 3 months with full explanations of all questions . My biggest mistake was that, I give only single read of UW, better was to give it 2 rounds. I would advise you all to give at least 2 rounds of UW . U world is essentially everything on the exam. It covers almost all the concepts, fact and materials. You will ever need to famalarize yourself with. Upto mid of july my study rhythm was regular, healthy and smart. Them suddenly my SISTER passed away, because of this wrost condition I suffered from severe Depression. At this moment I harshly disappointed , optisim was at my legs, so because of all these reasons my study rhythm was beatly fall down. When I completed first round of UW upto 15 August then I took NBME 13 ; at 20 Aug AND I FAILED !!! Yes, I failed tremendously, got only 150. It that moment I was broken down into segment, it was even worse than Breakup ! During this exhausted moment I contacted Dr. Hamza Aftab, very polite, humble guy. He encouraged me a lot and pushed me towards my targated goals.
SEP 2018 – 30, OCT 2018 :
I started once again First with UW notes . At this time I read 100 cases of ethics, khan cases of ethics, UW Biostatics and taken 6 reads of pathoma , as per part of my university exam. I think that I get much advantage of it !.
NOV 1, 2018 – DEC, 19 2018 : ( time of my fourth year exam )
At 12 nov , my fourth year annual professional was started and I covered ENT in 3 DAYS, COMMUNITY MEDICINE in 3 DAYS, and EYE in 5 DAYS. So till 19 Dec my exam finished.
DEC,19 2018 – EXAM DEADLINE ( 13 FEB 2019 )
After finishing my 4th year exam at 19 dec then without any delay, I started my journey once again, just next day of my university exam. I got up 6:00 am, had breakfast and reached library. There was no one in reading room, I choose single corner table, opened my laptop, FA and got settled myself. Them I closed my eyes , had deep breaths, started feelings my beats, recollected that last year`s moment when I had to allow my tears to mix with soil, whispered my deepest sorrows to highest heavens and ROSE UP ONE MORE TIME TO LIVE AND MAKE MY DREAM HAPPEN.
Once again I started FA with my own UW notes . I did not use anything besides this mentioned sources, and revised my FA upto 9 jan, and took NBME 17 ; at 9 jan2019, and scored 215 , little cofident and was happy that you can. After NBME 17 my strategy was to cover my weak areas in NBME. After covering my weak areaa like cvs, cns psychatry, in NBME 17 , then I took another NBME 15 : at jan 25 got 230, YES ! , during this time I get myself much confident , happy and optimistic. I covered my weak areas of NBME 15 ; then I took NBME 16 ; at 2 feb ; and scored 234, After that I took UWSA 2 at 5 Feb and scored 239 , with this gradually positive improvement I felt myself much happy. I took NBME 18 and scored 240 , with this motivated positive score, I get my wings and was hopeful to achieve my target, and I booked date for real at 13 FEB 2019.
At the end of exam, I laughed at myself; Ohhhhhhhhhhhhhhh……..!!!!!! She broke up with me in just that 8 hours; and I was madly in love with her for more than 8 months.
Moral of the story :
The exam really was very much like what usmleworld it as. Exam has increased in difficulty overall, and timing did become an issue for me especially in the first block were I had to resort to guessork towards the end but this more attributable to my sleep problems rather than the exam itself. I will note write what topics where tested or what was the distribution of subjects and I strictly advise you not to do that either. The repercussion include ban from taking USMLE exam for a limited number of years! So do not disseminate exam information anywhere, even under the veil of anonymity internet provides you!
ALWAYS REMEMBER SUN RISES EVERYDAY!!
Chandka Medical College( SMBBMU), Larkana, pakistan.