11 Lessons from USMLE Step 1

My Study Board

My Study Board

It’s over.  I killed the beast.  Tackled the giant.  Conquered Goliath.

Last Friday I took USMLE Step 1; arguably the most daunting test in a doctor’s career.  I dedicated 7 1/2 weeks, 6 days a week, 12 hrs a day to study for this test.  Unlike other accounts I’ve read, my test day felt great.  I went into the test knowing that I couldn’t have tried any harder, so come what may.  There were certainly questions that stumped me, but I felt that my test was easier than uworld, and about equivalent to the NBME’s.  The evening after my test my smile grew wider and wider as I realized it was over.  It has felt unnatural to wake up the last couple of days and not immediately walk into my office to start going through uworld questions by 7 am.  I’m remembering that I have family, friends, and hobbies.  Life is immeasurably better, and I swear spring waited until now to bloom just for me.

I want to share with you 11 things I learned while studying for Step 1.

1. You can never learn First Aid enough.  If you think you have mastered every minutiae in that 600+ page review book, think again.  Review review review.  Every detail in that book is fair game, and you will be expected to know the difference between very similar diseases based on tiny incidental findings.

2. Questions questions questions.  I am extremely grateful that I completed the USMLErx qmax qbank before I started uworld.  I started USMLErx during my last block of M2, and I finished it the first week of my dedicated study period.  I treated this question bank as my first pass of First Aid, and it allowed me to hit uworld running.  Between question banks and practice tests, I did over 6,000 questions.  Very worth it.

3. Make sure you are learning the concepts behind the questions you miss.  Evaluate every missed question.  Was it a simple mental error?  Was the material completely new?  Was it a concept you keep forgetting, regardless of the number of times you learn it?  Once you’ve identified the problem, record the lesson you learned in a manner that is easy to retrieve.  For example, for each question I missed I did three things: I wrote the lesson I learned in a notebook, I annotated it into First Aid, and I made an anki digital flashcard.  You have to find a way to do this fast while still being thorough.  It takes a lot of time initially, but practice makes perfect.  This meant that I was constantly reviewing the concepts I had learned as I read First Aid, reviewed my daily flashcards, and read through my notebook.

4. Carefully select the location you study in and be consistent.  I chose to study at home.  This made sense to me for a couple of reasons.  We don’t have any children yet, and my wife is very busy at nursing school, so I knew that my home would be quiet.  I also have the benefit of having a home office.  I made sure to do all of my studying in the office, so that I wasn’t sick of the rest of the house on the rare occasion I left my study cave.  I made sure my office was stocked with water, whiteboard, food, tissue, light, etc.  I only intended to leave my study space to use the bathroom and to find more food.  Wherever you decide to study, make sure it is a place you can consistently use.  I would only suggest studying at home if you are guaranteed solitude, and have a room that you will only use for studying, thus protecting the rest of the house from your Dr. Jekyll and Hyde moments.

5. Plan consistent breaks and use them wisely.  Studying for this test is a mental marathon.  Don’t try to sprint your way through it.  I scheduled a basketball break from 12 – 12:30 pm, lunch from 12:30 – 1 pm, and a 15 minute guitar break every two hours

6. If you’re tired, switch to a different study source.  There will be times your productivity slumps and you simply cannot read another page of First Aid or correct any more uworld questions.  Instead of  taking an unscheduled break, try switching up your source.  I found that if I grew tired of reading, it was time to watch pathoma or sketchy micro videos.

7. Don’t take your loved ones for granted.  Realize that you are not the only one who is sacrificing for your test.  Your wife, roommates, friends, parents, or anyone else you normally associate with is going to have to put up with you.  On your days off, try your hardest to be a normal human.  Laugh if you will, but this is harder than it sounds.  There were times during my study period when I took my wife out to dinner, and the only thing I could talk about for conversation was the contraindications for monoamine oxidase inhibitors.  Thankfully Mrs. DebtAnatomy is very supportive and understanding.  However, show gratitude to those around you for their support, and make sure you dedicate your post-step 1 time to making up for lost time.

8. Take lots of food with you on test day.  You’ll be shocked at how hungry Step 1 will make you.  Treat yourself to your favorite snacks that day, and make sure you have twice the amount of food that you would normally eat.  Better full than hungry 🙂

9. Take a weekly practice test, and don’t let them get you down (for too long).  My sights were probably a little too high for my first couple of Saturday practice tests, and they put me in a sour mood the rest of the weekend.  It stunk, but I learned to use that feeling to my advantage.  When Monday came around, I was ready to throw myself into studying; determined to score higher on my next test.  With patience and a ton of hard work, my scores rose into my target range.

10. No Regrets.  You will not learn everything you want to.  You will not have First Aid completely memorized (even if you think you do).  But make sure that when you walk into your test you can be certain that you tried your hardest, you left it all on the field, and no amount of do-overs would change the outcome.  This is the only reason that I am sitting here comfortably before I even know my score.  Whatever number those three little digits show in three weeks, I’ll have the luxury of knowing that I did my best.

11. Take EVERYBODY’S advice (including mine) with a grain of salt, and do what works for you.  You succeeded in undergraduate school, you rocked the MCAT, and you got into medical school.  You know your study preferences better than anyone on student doctor network.  Find what works for you, stick your fingers in your ears, and ignore what your classmates are doing.

To everyone reading this who has yet to take Step 1, I wish you a warm good luck.

3rd year anybody?

EDIT: I have since received my score.  As most of my class knows who I am, I do not wish to post my score, because I do not want to be accused of bragging, etc.  However, I also realize that as a reader you might pay closer attention to my Step 1 advice knowing that I scored well.  So here is a compromise: Whenever I listened to advice, I paid extra attention to guidance from people who scored >250.  Using this bar of measurement, my pre-step 1 self would’ve paid extra attention to my post step 1 self.  If that’s not clear enough for you, then I suggest you study extra hard! 🙂   

47 comments on “11 Lessons from USMLE Step 1”

  1. Sunny Reply

    Thank you for great advice!! I am about to start studying for the exam and I just needed someone to point at the aspects outside of studying that helps you feel better and keep stay focused!!

  2. K Reply

    HI Mr. DebtAnatomy,
    I am an M2 3 months away from my exam (with 1 month of study period), and I’m considering purchasing USMLErx. Originally, I was going to purchase 3mo UWORLD at the end of January and do ~20Q a day until dedicated, rather than a whole 44Qblock so i can really learning the quesitons. But while trying out the flashfacts, I found USMLErx to be really awesome at pointing out things that I overlooked. I’m wondering if I should add USMLErx now to do quesitons relevant to the block I’m still on. I’m concerned that if I do too many questions everyday, I might not learn that much from UWORLD. I was wondering if you offer some advice (and if it’s not too much, how you setup your questions in terms of timed/untimed tutor. I would be very grateful. Thank you so much.

    • Mr. DebtAnatomy Reply

      I am SO glad you asked these questions. I am actually hoping to write a detailed post on how to properly learn from question banks. Unfortunately, surgery rotation is dominating my life for another week, so I’ll probably have to tackle it next week. However, some specific advice to your situation is as follows: USMLErx + UWorld is money. I am SO glad I did both question banks. The more unique questions the better. I was in a similar position to you when I started USMLErx. It was my final block, so I started doing a complete question set a day during school. For USMLErx I went through the qbank by topics. For example, my final block of school was neuro and psych, so naturally I did the neuro and psych questions first. Random, timed, unused. After the qbank session for that day I would correct my test (more details in my future post). I made sure to finish USMLErx a week and a half into my dedicated study time (I had 7 total weeks of study time, and I calculated out when I needed to finish USMLErx so that I would have sufficient time on UWorld. This naturally required me to complete several other topics on USMLErx during my final block of school.

      So in summary, the greater number of questions the better. But the trick is to make sure you are still learning from the questions. This will be addressed in my next post. Stay tuned for Mr. DebtAnatomy’s “How to learn from UWorld and USMLErx”.

  3. Alp Reply

    Gr8 post to tackle any competition.
    Wat books wud u recommend to person who has to start prep for step one….first attempt no less.

    • Mr. DebtAnatomy Reply

      Great question! There are a billion resources out there that can distract you more than help you. I kept my study strategy very simple. The resources I used were: First Aid, pathoma, uworld, usmlerx, sketchymicro, and lange pharmacology cards. I never used a separate textbook other than first aid during my dedicated step 1 study. Textbooks are super important during the first two years of medical school, but by the time you hit step 1 study you need to focus on the essentials found in First Aid. If you run into something you are unfamiliar with in First Aid, look it up on wikipedia, and if you are still unsatisfied, then look it up in a text book you used during the first two years of med school. Does that make sense? Let me know if you have any other questions.

  4. Well wisher Reply

    Hey, I don’t usually post on webpages, but I couldn’t ignore this because I could sense the honesty in your writing. Thank you so much for genuinely sharing these excellent suggestions. I have 9 weeks of dedicated study time left before I get to write the beast! I have completed 40% of usmlerx so far. My goal is to finish all of usmle rx in the next 2 weeks and start uworld after that. I’m really curious what you did during the 7 week period? how many times were u able to go over uworld? How many nbmes were u able to do? When did you incorporate goljan and pathoma? I know u mentioned you took one practice test every week does that mean 7full blocks? Or a four hour long nbme?
    I’m so sorry for bombarding you with so many q’s. I will be so thankful for any suggestions you can offer. Thank you and best of luck!

    • Mr. DebtAnatomy Reply

      Finishing usmle rx with 7 weeks left is perfect! The majority of those last 7 weeks should be spent on uworld. It took me around 5 weeks to go through uworld thoroughly, doing 3 question sets a day, 5 days a week. I did one nbme each week, except for the last week when I did 2 nbme’s back to back to simulate the real deal (8 hours, so it was actually longer than the real thing). I finished uworld with about 2 weeks to go before the test, and my initial goal was to use this time to go through uworld again. However, I quickly realized that I recognized a lot of the questions and it wasn’t helping me. So instead I used those last two weeks to do 1 uworld question set a day and I only did questions that I had gotten incorrect the first time around. I used the extra time during those last two weeks to do a second pass through pathoma and first aid, and to review all the notes and flashcards I had made. This was perfect for me, because I was able to to a massive review of information, while still staying in question mode by doing 1 set a day.

      As far as pathoma, I watched an hour every night during the 5 weeks I was doing 3 uworld question sets a day. Then the last 2 weeks I watched 3-4 hours a day, making sure that I went through pathoma twice in total. I never listed to goljan, but I heard it was great.

      Hope this makes sense. I’m writing it on the fly. Let me know what other questions you have. I am going to write a post tomorrow morning detailing how I learned from doing question sets.

  5. Well wisher Reply

    Thank you so much for sharing your experience. I really like how you organized time for everything into a breathable schedule,it is really helpful, especially since I’m basically doing everything the way you did. 🙂
    Could u share your stats with us on how u scored on the nbmes from beginning to end? It would be great to use as a comparisent. Also, I really look forward to your next post on how you learnt from qbank questions. Thanks for all the help!!

    • Well wisher Reply

      The other question I had is how much time per day did u spend reviewing your flash cards/ notebook? I’m having a hard time making time to review my past mistakes and stick to the schedule at hand. Any suggestions for this?

      • Mr. DebtAnatomy Reply

        I talk about this a little in my new post. I scheduled an hour in the early evening to go over flashcards. Then later in the evening the last hour was usually spent going over my notebook plus more flashcards if I felt like it. I set up anki to give me 50 new questions and 50 old questions every day.

    • Mr. DebtAnatomy Reply

      For sure! I’m going to write a follow up post on how to use nbmes. But for now, here’s the scores in the order I took them: UWSA1: 218, NBME 12: 228, NBME 11: 232, NBME 16: 245, NBME 17: 243, NBME 15: 256, UWSA2: 264. I took my first practice test 2 weeks into my dedicated study period, which means I had finished USMLErx and was 1 week into UWorld. Check out the new post!

  6. Dr. Pratiksha Reply

    Mr.Debt anatomy, its great that you got such an amazing score on your step1.
    I’m an IMG from India and i plan on taking the step 1 this december so i have lie a prep time of 20 weeks.My plan is to understand every concept in first aid and as many passes of uworld as i can.
    How important is pathoma or goljan for my preparation or is it enough if i look through the pathology given in FA??
    And also for subjects like neuroanatomy and molecular biology will FA suffice??

    I am an average medical student but i am willing to work hard for this exam.
    Please help me out.

    • Mr. DebtAnatomy Reply

      I would highly recommend doing either pathoma or goljan, and if you have enough time (which it sounds like you do) then do both! I didn’t use any extra texts for neuroanatomy and molecular biology, but I made sure that I new the stuff in FA really well.

  7. Reem Reply

    Dr thank you for the valuable post
    It’s just great and your narration is superb.
    I’m an IMG grad American citizen though. I’m currently urology resident abroad. Then moved permanently to the US so I have to go through usmle:).
    Your study plan gave me high hopes as its quiet similar to mine only difference is that I’m almost grad since 4 years and my old knowledge is a bit far away.
    But I’m still doing my usmle rx as a start and willing to follow with u world.
    I need your flash cards as a guided example as I’m doing mine and also to feel secure that I’m backed up if I missed something.
    If you don’t mind please send me a copy.
    Ofcourse I understand there is a very high probability I won’t match for urology but I’m still determined to do my best and wait for the outcome.
    Good luck in your career
    Thank you

    • Mr. DebtAnatomy Reply

      Thanks for the great comment! I wish you the best with your future! I just sent the flashcards.

  8. Heena Reply

    Hey, I’m using the same qbanks as you did. I read your other post about how you scheduled your day & how you took notes off of world. I’m thinking about closely following that. I’m currently using the usmle rx qbank. I was wondering, did you take notes on that as well? I’m saving my annotations into first aid for uworld. But anything that’s new to me or I don’t understand I put it in anki. I’m afraid I might be wasting my time doing that & accumulate too many flash cards for qmax. Plus I’ll have another deck of uworld flashcards when I go through uworld. So should I just save anki for uworld as well? What was your routine for going over qmax? Did you go over all the questions or just the ones you got wrong & right but wasn’t sure about the answer in qmax?

    • Mr. DebtAnatomy Reply

      Great question! I always went over all the questions, but paid more attention to the ones I didn’t know. I did make anki flashcards for usmlerx. Happy studying!

  9. David Reply

    Thanks for the post. It was really insightful and I could tell you knew you wanted to set yourself up for success and not just hope for the best.

    I am a first year medical student and our school takes Step 1 & 2 after we complete our 3rd year rotations. With that in mind, I am well aware that the test is very far away but I want to do small things now to set me up for success down the line. What would you suggest for a first year who wants to be proactive and start on some resources now?


    • Mr. DebtAnatomy Reply

      Great question! The MOST important thing you can do during 1st year is to rock your current classes and REALLY understand the material that is being covered. That way when you start board studying mid 2nd year you will be reviewing material instead of having to learn things for the first time. If you feel like you are already doing well in classes, then I would suggest getting into pathoma and sketchy micro.

  10. M Reply

    Hello ! I have a question. Does it help to really know FA in and out before you tackle Uworld for the first time? I read FA(Pathoma as well) in Nov through Dec 2016. Then did Rx in 8 weeks while reading parts of FA relevant to the question..I’m not sure if I remember everything in FA. So should I revise FA quickly( which would atleast take 15days for me ) or just directly start uworld in random, timed mode ? I am an IMG hoping to take the step In mid June.

    • Mr. DebtAnatomy Reply

      The more you know first aid, the better off you’ll be. It sounds like you have plenty of time to go through Uworld before you take your test. One thing you could consider is doing some kaplan questions between know and when you start uworld, since you have a lot of time between now and your test.

  11. Sally Reply

    Thank you for all your advices .. can I have a sample of your flash cards to leaen from it?

  12. George Reply

    Really whish is the difference between Qmax and Uword And which is more similar to the exam?

    • Mr. DebtAnatomy Reply

      The general consensus is that Qmax is much more straightforward than the real text. Basic fact recall, etc. Uworld questions tend to have several layers of thinking that you have to go through to get to the correct answer. The real question tends to be between the two in terms of difficulty. Again, this is based off general consensus. I have heard people say they felt like their real test is more like Qmax, and others that it was more like Uworld. In my experience, it felt like a good mix of the two.

  13. Alvin Reply

    Hey congrats, i have a questions, i did it backwards, i started using Uworld, now im using Rx( wanted to buy Uworld again but didn’t have much money jeje and i preferred to use another different qbank also) do you think RX is still good for your prep? , a learned a lot from u Uworld and it’s noticeable by now.

    • Mr. DebtAnatomy Reply

      I think that will work fine! RX has great information in it and will certainly help. I would definitely recommend doing UWorld and RX as opposed to just UWorld twice.

      • Alvin Reply

        So i had this massage from Uworld “Our products consist of focused, high yield, and up-to-date content and explanations that meet the current objectives of the real exam. Each question requires a three to four level mode of thinking, which is much more difficult than what you would encounter on the actual USMLE exam. Moreover, our practice exam questions are much harder, making it much more difficult for an average student to score high in the first few attempts. The goal is not to discourage students, but to motivate them to study harder and smarter. UWorld questions are designed to test the difficult part of the examination content while incorporating the less to medium difficult concepts in each question’s explanations.

        In addition, we continuously update our questions to ensure that our high quality questions match the changing standards of the actual USMLE. After ample preparation, practicing as many high quality questions as possible is the key to scoring high on each USMLE exam.” do you think it’s true from your experience?.

        • Mr. DebtAnatomy Reply

          Yes, I would agree with that statement. In general, UWorld questions are harder and require deeper thinking. I thought that my actual Step 1 test had a lot more questions similar to the most recent NBME’s, although there were still plenty of questions that were as hard or harder than UWorld. UWorld is by far the best question bank.

  14. Dana Reply

    Hi I’m currently studying for step ,grateful that i found your site (love the site)

    would it be possible to see your anki cards?

    Thank you,

  15. Kit Reply

    Hi! Congrats on crushing this huge exam. Would you please send me your anki flashcards. I just love Anki!

    Also, is it advisable to use Anki as a primary tool for revising FA(so in effect setting aside like 3-4 hours for Anki daily)?

    • Mr. DebtAnatomy Reply

      Just sent the cards. If using Anki as a primary tool for revising FA works for you then do it! I only spent about an hour per day studying anki (though if you include the time it took to make the flash cards each day while correcting question sets then it would be closer to 3-4 hrs of anki). Good luck!

  16. Saira Reply

    Hello Dr. Debt.

    I’m an IMG preparing for step 1 since last 3 years. Many distractions came along my way. I got married moved to different country etc. I dedicately started studying from march 2017. I did uworld once. Doing incorrect now with score ranging in 80’s. all my friends say this score for incorrects is not good. I bought usmlerx to do different questions but honestly it was making me more depressed so I stopped it. I was scoring either equal to average or 2-3 % above average. I thought after finishing uworld i should have scored alot more in rx. Should i finish rx or do uworld again n again? i have read first aid a million times by now. Still reviewing it. I’m confused because i think i should have started rx before uworld but I didn’t. Now doing it feels like im not focusing on the right thing here. What should i do?

    • Mr. DebtAnatomy Reply

      Sorry for the late reply. I was on a busy rotation.

      Uworld and Rx have a lot of unique questions between the two of them, so don’t feel down if you don’t do as well on Rx as you think you should. In fact, the benefit of doing two different qbanks is that it exposes you to brand new questions, instead of just going over uworld again and again.

      Good luck studying!

  17. Raj Reply

    Mr. DebtAnatomy,

    Excellent post thank you so much for putting your time. Could you send me anki flash card for my step 1 prep.

    Thank you

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