The USMLE Step 1 Experience

Dr. Brandon D’Souza is an intern from the batch of 2015. He has cleared his step 1 exam and is pursuing USCE(US Clinical Experience). He aims to do his residency in Neurology.

The USMLE STEP 1 is an absolute behemoth of an exam. I had written the exam on September 29th of 2021 at the Prometric Centre in Dubai and I got my result exactly two weeks later. The exam was about 7 hours long with a break time of 1 hour that had to be taken in between blocks. (Each Block comprised of 40 questions, 7 blocks in total with an hour allocated to each block).

What no one tells you about Step 1 is how hard of an exam it is- it tested my resilience and mental endurance in almost every which way. This is not to discourage anyone from applying but to bring the reader to the reality at hand. It was definitely one of the most difficult exams I’ve given so far in my professional career and especially difficult for us IMG’s (International Medical Graduates) as we aren’t taught how to approach such standardized tests during our med school.

Studying for Step 1 has been the most alienating experience- long nights, mental blocks, being cut off from the world for an extended stretch of time have been a part of my journey, and in hindsight, these were a necessary part of the process. Unless you have already been a stellar student during college, standardized tests are really difficult to ‘crack’ as the cutoffs reach very high. The passing grade on Step 1 requires you to score at least a 65-70% on the real deal.

Now let me take you through the study material, question banks and practice tests that I used and how they compare with the actual exam :-

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The USMLE STEP 1 is an absolute behemoth of an exam. I had written the exam on September 29th of 2021 at the Prometric Centre in Dubai and I got my result exactly two weeks later. The exam was about 7 hours long with a break time of 1 hour that had to be taken in between blocks. (Each Block comprised of 40 questions, 7 blocks in total with an hour allocated to each block).

What no one tells you about Step 1 is how hard of an exam it is- it tested my resilience and mental endurance in almost every which way. This is not to discourage anyone from applying but to bring the reader to the reality at hand. It was definitely one of the most difficult exams I’ve given so far in my professional career and especially difficult for us IMG’s (International Medical Graduates) as we aren’t taught how to approach such standardized tests during our med school.

Studying for Step 1 has been the most alienating experience- long nights, mental blocks, being cut off from the world for an extended stretch of time have been a part of my journey, and in hindsight, these were a necessary part of the process. Unless you have already been a stellar student during college, standardized tests are really difficult to ‘crack’ as the cutoffs reach very high. The passing grade on Step 1 requires you to score at least a 65-70% on the real deal.

Now let me take you through the study material, question banks and practice tests that I used and how they compare with the actual exam :-

STUDY MATERIAL AND QBANKS

• Uworld -

Uworld should be your primary resource. It is a great question bank that contains about 3700 questions. Each and every question is High yield from the exam point of view. The interface is very similar to the USMLE Step 1 exam, which helps you condition your mind to the pattern as well as the layout of the exam. Going through all the questions of Uworld twice, followed by hammering the incorrect into your brain should be sufficient, in my opinion.

•Amboss -

Amboss is the next best Qbank after Uworld. It has about 2500 questions. These questions are usually more difficult than Uworld and they aren’t

an accurate representation of what you will get on the actual exam. However if you’re looking to solve more questions after Uworld as a confidence building measure, Amboss is the next best thing.

• USMLE RX -

Honestly there isn’t much that can be said about this particular Qbank as it isn’t entirely representative of the real Step 1 experience. With that being said, it is a great way to consolidate First Aid and as a side note, the ‘Rx Bricks’ are highly underrated.

* First Aid -

This is hands down the only book you need for Step 1. Do not use it to study for it is meant to be used only as a review book. It is especially helpful during the final month of prep to revise everything as you have most of the high yield stuff in one place- making it easier and faster for you to flip through the high yield content multiple times. I highly recommend using a Digital Copy of First Aid.

I did not use Pathoma/Sketchy/Pixorise/Boards and beyond/Anki. I am planning on making my own Anki deck for Step 2.

MOCK EXAMS

•UWSA’s -

Uworld provides you with two self assessments. UWSA 1 and UWSA 2. Both of them are equally difficult. The UWSA 1 has a more lenient curve hence, it tends to overpredict your score. The UWSA 2 exam result was closer to my real score.

•NBME -

The NBME mock exams are hands down the most important resource during your last few months of preparation. One should start taking NBME’s 2 months before the real deal. They are basically past Step 1 papers and comprise of 200 questions (As 80 questions on the real exam don’t count). My actual Step 1 exam was closest to the NBME’s after all, it is the NBME that prepares your exam questions.

Note :- The NBME’s are pretty difficult. In order to get a 240 on an NBME you have to score about 85% which is insanely high once you get down to think about it. My first NBME was a 182 which was actually a fail score, so do not get discouraged in the beginning. Once you pass atleast 3 NBMEs, you should consider giving your step 1 immediately (as the USMLE Step 1 has become a pass/fail exam and will not be graded with a numerical 3 digit score).

Free 120 -

I highly recommend you take this exam at Prometric. You will need a separate scheduling permit. The exam will be be a mix of Free120/NBME’s/Uworld in that order.

MY TIPS FOR THE DAY OF STEP 1

* Reach about half an hour early to your centre as they will let you give the exam earlier. Priority is always given to USMLE examinees.

* Wear something comfortable and make sure to give a light smile at yourself when they click your picture before you enter the exam hall. You will be looking at your face every time you start a block so it is best to look calm, for your own sake.

* Be prepared for any uncertainties on exam day. I had a glitch where my final block started automatically. I just let out a big sigh and moved on. Do not lose focus or get panicked when you encounter such problems.

* You’re not going know everything on the exam and that’s fine. The only thing you have to worry about is the current question you’re on. Unless you’ve marked it for review, don’t think about changing the answer unless you’re absolutely sure.

After you’re done with Step 1 you should :-

* Destress destress and destress - Blow out steam, for the PTSD (Technically Acute Stress Disorder) is real (on a lighter note). You will get flashbacks of stupid mistakes and worrying about your scores at that point is just self destructive.

* Meditate - Unconventional I know, but I prayed a lot on the day of my result and I got exactly the score I needed for my desired specialty. Sometimes prayer/meditation can really help you with your neuroses.

* Do the things that you love.

Immerse yourself in all the experiences you deprived yourself of. Do all the things that you couldn’t do while studying for this absolute monstrosity of an exam. Get back to your hobbies or learn a new skill (it literally feels like the world is your oyster after you’re done with your step 1, atleast for a few moments).

Cherish those moments because after step 1 comes Step 2 which is another battle to be fought. Step 2 is the new step 1 which gives most of us a lesser shot at redemption if we have underperformed in step 1. However if your step 1 knowledge is good, step 2 will be comparatively easier to tackle as it requires a step foundation which can be built while preparing for step 1.

All in all it was a humbling experience. I definitely appreciate medicine even more now. I know there are many of you who are still undecided or are confused but trust me when I say this, you will fall in love with medicine after preparing for this exam. Your concepts will be strengthened.

Also, keep in mind that scores aren’t everything. Even graduates with the best scores sometimes don’t end up matching. It all depends on your all round CV so make sure to work on your US clinical experience, publications, volunteering and other certifications.