The Step 1 Examination: Preparation and Test-taking Strategies

By Ali Haider Jafry

I was able to take the Step 1 exam on the 20th of September, 2017 in my final year of medical school and managed to score 266, Alhamdulillah. Since a lot of articles detailing the exam’s structure and test-takers’ experiences already exist, here I shall only briefly outline my own experience and try to highlight some of the more important ways in which I had to differ from other students’ preparation strategies.

Kaplan Textbooks and Lectures: Anatomy, Physiology, Biochemistry, Pharmacology, Microbiology, Immunology, Behavioral Sciences
Pathoma and Dr. Sattar’s Lectures for Pathology
UWorld Online
Conrad’s 100 Cases for Ethics
Step 2 CK Psychiatry Offline
Biostatistics UWorld Offline

I made my decision to take the exam halfway through my 4th year in medical school. In the same year, I took up the Kaplan textbooks for Anatomy, Physiology and Biochemistry and studied from Pathoma for Pathology. Once I was done with my final examinations for the year, I began with the rest of the Kaplan textbooks in early March. It took me till the end of April, 2017 to get done with the Kaplan textbooks and lectures once. I took a month to revise all of the textbooks once, then took up FirstAid by the end of May, read it fairly quickly (you don’t need to cram everything the first time around, just go through it and revise what you already know) in about 12 days and then moved on to UWorld. I did all of the blocks in the random timed mode which, in my opinion, made all the difference in my preparation. While doing UWorld, I did not resort to FirstAid (except to jot down the more high-yield information from UWorld) for revision of topics or any other book for that matter since it would have taken up too much of my time. By mid-August, I was done with UWorld, had taken my date for the exam and thereafter began my revision of FirstAid which was by now filled with all the information I had transferred to it from UWorld. It was then that I also studied the Biostatistics and Psychiatry Offline UWorld questions, which helped me greatly in refining my performances in those two subjects. I then began giving online assessments in quick succession (a test per day) from the 1st of September as follows:
1.       NBME 13 online - 252
2.       NBME 15 online - 250
3.       UWSA 1 online - 273
4.       UWSA 2 online – 262
Here I took a week to read my FirstAid for the third and final time before the exam. During my final week, I gave the remainder of my self-assessment tests:
5.       NBME 16 online- 255
6.       NBME 17 online - 260
7.       NBME 18 online - 265
8.       NBME 19 online - 255
9.       NBME 12 and 7 offline
I tried to not burden myself the day before the exam, bought some supplies for the next day [fruit juices, canned coffee, paracetamol extra (contains caffeine), chocolates, water etc.]. Take care not to heighten your anxiety by using too much coffee and avoid amphetamines as well.

A few important points:
·         Take some time to decide why you want to go down the USMLE path. Discuss it with your family and make sure you have a strong support system to turn to when things are not going as planned. Do not take this exam lightly but don’t make it out to be bigger than it is. It’s just a test in the end, like so many others you’ve probably given before. Try to make a good routine for yourself and don’t isolate yourself socially.
·         The Kaplan textbooks and lectures are for building your basics only. Do not spend too much time on them or annotate your Kaplan notes on FirstAid. Also, do not start your preparation for the exam directly with FirstAid or UWorld unless you’re sure your foundations are well-established. You may resort to any of a number of good books for this initial phase but I would highly recommend the Kaplan Biochemistry lectures by Dr. Turco and the Behavioral Sciences lectures by Dr. Daugherty. The resources I’ve mentioned are more than enough so try not to waste time on doing the subjects in great detail.
·         FirstAid cannot be learned by heart, no matter how hard you try. That is where UWorld comes in; the questions in UWorld will help you know which information is high-yield and which isn’t. E.g. you can’t possibly memorize all the side-effects of every drug, you usually only need one or two.
·         Owing to time restrictions, I was unable to begin my revision of UWorld and had to restrict myself to only revising the questions I had gotten wrong on my first go at it. However, I had a good score (81.5% correct) and percentile rank (90th), so I considered myself ready for the exam.
·         A lot of students tend to use UWorld as a learning tool only during their first go at it, doing it system- or subject-wise. The Step 1 is not just a test of knowledge; more importantly, it tests your ability to think critically and the best way to attain that is to use UWorld in the random timed mode the very first time that you use it. This was part of the reason why I scored well in spite of having gone through UWorld only once. I would also recommend doing it online since it is a better judge of your performance.
·         Try and pace yourself for the exam while doing UWorld e.g. begin with a block per day for the first week, 2 blocks at a time for the next 15-20 blocks, then 3 and so on. It’ll aid you greatly in pacing yourself for the real thing. Spread out the days for reading the explanations as you see fit. Try and finish UWorld within one and a half to two months. I think it’s quite manageable, since I was taking my classes and wards at the same time and managed to do it within 2 months.
·         Revising FirstAid 7-8 times will not do you any good. I believe that 4-5 reads of it are more than enough. I actually felt I had begun to lose much of the information I had amassed by the third read.
·         The overall timeline for the exam should ideally not extend to much more than 6-8 months. The preparation itself is a drain on your body and spirit. Anxiety is common in the weeks leading up to and the time after the exam as well. Keep this in mind when outlining your timeline!
·         The ideal time to give the exam would be within a month of revising UWorld. Do not postpone the exam date unless it is absolutely necessary. I’ve seen many students delay their exams out of fear of not being prepared for it or not scoring as good as they would’ve wanted on the self-assessment exams. I do not believe it will do you much good; once you’re done with UWorld twice and have given FirstAid 3-5 reads, you’re at your peak in terms of knowledge and test performance. After that, the information just gradually seeps out and if you’ve used up your NBMEs and UWSAs, you won’t have a tool to judge yourself with.
·         As you may see from my timeline, I was of the opinion that I would use my self-assessment tests once I was sure my preparation had reached a peak and I was ready to take the exam. Students do use the NBMEs and UWSAs to gauge improvements in their performance but if you’re scoring well in UWorld, you might as well hold on to the tests since they come in handy later on for preparing you for the real thing.
·         For me and quite a few of my colleagues, NBME 18 was most predictive of our actual scores. The UWSAs are too generous while NBME 19 has a harsh curve. But don’t get too stressed out over how to take these tests and in what sequence. Scoring consistently is more important than scoring a 260 on one NBME and a 230 on the next. As long as you’re getting consistently above the 240’s, you’re on track for at least a 250 plus score!
·         Try to book your date for the exam at least 2 months out. A lot of students are unsure of the date they want and so they put it off, only to find out that those dates aren’t available in the city of their choice. So try to book your appointment early and then do your best to stick to it.
·         Try to be discrete when preparing for the exam. I actively avoided study rooms in my hostel and university and it helped me avoid much of the pressure that comes with the expectations of people who know you’re preparing for the exam.
·         The actual exam environment is really noisy since GRE test-takers are also usually present. Be prepared for this by taking your self-assessment exams somewhere that isn’t completely quiet. It’ll help you immensely during the exam.

On the Day of the Exam:
·         Print out 3-4 copies of the scheduling permit a week or more in advance to be on the safe side, have your passport made since it is required for the exam and remember to take your ID card with you as well.
·         Wear comfortable clothes with as little pockets in them as possible since it’ll help you with the check-in process during the exam. Also take a jacket or sweater with you in case it gets too cold for you.
·         Arrive at the test-center early and plan your commute beforehand, taking any roadblocks, protests etc. into account. You should receive a call from the test center as well in the days leading up to the exam confirming your appointment and the time you should arrive at the center.
·         Beginning at least a month before the exam, try to go to bed early, getting a good 8 hours of sleep. It is perhaps the most important step you can take to ensure performing well on the day of your exam. On the night of the exam, an over-the-counter sleeping pill (antihistamine) may come in handy, as may hypnotics such as Zolpidem but try to avoid benzodiazepines if you can.
·         Read the questions very thoroughly, decipher what concept the question is testing you on and try to come to a conclusion about the answer, if it’s possible, before even reading the answer choices. This will help you avoid ambiguity about the correct answer. For lengthy question stems, it helps to read the last line first.
·         There are always hints and clues in the question stems, sometimes as small as a single word. You need to accustom yourself to catching these on UWorld and NBMEs.
·         Choose the very first option that comes to mind for answering your questions. It is the right choice for most test-takers. Orient yourself to always think that your first hunch is the correct one and then if you suspect it may be wrong, give yourself solid reasons to change your answer.
·         Be prepared to face about 5-8 or even more questions on each block that may seem to be really hard to answer. Reason your way through them as best you can, make educated guesses and move on. There are usually small clues in the question stem that you may miss out on in the first read. So mark the questions and read the stem again at the end of the block if you have time.
·         Depending on the test’s difficulty, you may find yourself with ample time at the end of each block or you may not find enough time to completely go through all the questions thoroughly. For me it was the latter, even though I would always have a good 10-15 minutes left at the end of each block in UWorld and the NBMEs. Do not be fazed if this happens; instead, think that if the exam is tough, you have a better chance of scoring higher on it!
·         You may take your break time as you deem fit, based on your experience from UWorld and NBMEs. I took ten minute breaks at the end of each block, taking a sip of coffee and eating some chocolate every time I did so. This strategy helped me regain focus for the next block, recharge myself and rest my eyes for a while.
·         Everyone makes simple mistakes on the exam. Do not beat yourself up over it; just brush it off and move on to the next block.
·         Lastly, aim for a good score but keep your expectations reasonable!

Once you’ve given the exam, relax and take solace in the fact that you’ve given one of the most competitive exams in all of medicine. You’ll receive your score exactly three weeks later. I believe it’s important to state here that every student has his/her own way of going about preparing for the test, so this article is in no way meant to dictate how you should study; it is only to help guide you on your way. I wish you the very best for this journey!
Ali Haider Jafry
King Edward Medical University, Lahore


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