While the last several weeks were some of the darkest of my life, I did survive them somewhat painlessly, as well as the last two years of medical school. It honestly feels a bit surreal to be writing this right now, as Step One is a tremendous hurdle. The first two years of medical school are no cake walk either. Despite this, or perhaps due to this, I am a firm believer in maintaining sanity and happiness through efficiency and efficacy. I have talked about this previously, with respect to general study tactics, as well as in relation to First Aid (hereand here), a famed Step One Resource. Spoiler, I am not a huge fan of this book, but more on that later.
Relevant Step One Statistics
Before diving into any advice, it is important to deconstruct the gloom and doom that surrounds this infamous exam. The standard error of measurement incorporates both the standard deviation and reliability of a test. Basically it represents how much an individual examinee’s score would vary if they took a test that covered similar material, with different questions, repeatedly. Can you guess what this is for Step One? It’s 6 points. Assuming a normal distribution, 68% of this student’s scores will fall +/- 1 SEM, while around 95% will fall within +/- 2 SEM. In short, this means that Step 1 scores are not perfectly precise measurements of knowledge. Unfortunately, this imprecision is generally not considered when they are interpreted.
Now, how do we go about comparing scores from student to student? Well, this can be deduced utilizing the standard error of difference. We can be confident in statistical difference when two scores are greater than or equal to 2 standard errors of difference. The USMLE publishes the standard error of difference as 8 points. So, to have 95% confidence that two candidates truly have a difference in knowledge, their Step One scores must be greater than 16 points apart. Once again, rigid residency cutoffs do not consider this.
Next, to illustrate the Step One arms race, let’s look at score trends over recent decades. Contrary to popular belief, Step One has never undergone a restructuring like other standardized tests. Translation: students today score higher on Step One by virtue of the fact that they are answering more questions correctly. Personally, I would attribute this to two things. First, the greater emphasis on the result has propelled students to excel to a greater degree. Second, the study resources have allowed for vast improvements. For instance, I would be lost without UWorld as my primary study resource. This makes sense as poor medical students are often guinea pigs and cash cows for anyone and everyone. Cold, hard numbers can best illustrate the drastic change in performance. In the early 1990s, 200 was a respectable score, being the mean. Today, 200 lands you in the 9thpercentile, which is no longer so respectable.
Circling back to differentiating between candidates, roughly how many questions do you think determines this? After all, of the 280 questions on the exam, some are experimental and some are home runs, which most candidates get correct. The remainder are what truly separate students. Perhaps I shouldn’t use the word home run though haha, as Step One is a beast. Let’s call them relative home runs though. The original analysis, as well as a greater dive into the concepts I have covered thus far can be found in the original article. Ultimately, the author arrives at the conclusion that roughly 85 questions determine a score range in the neighborhood of 81 points. This is insanity! To put it into perspective, this equates to approximately one point per question.
So, why bring all this up? I believe everyone has different natural potentials, based on their innate test taking abilities, critical thinking skills, as well as ability to conceptualize, memorize, and apply concepts. That being said, there is also a range in which you can fall based on the effort you put in. For example, two candidates with differing aptitudes for the exam can arrive at the same score, but this may require the less gifted student to put in quite a few more hours. Ultimately though, you need to put in a certain amount of work, which is specific to you, to get to a certain threshold. Beyond that, you are victim to the statistics I elucidated above. If you internalize that positively, you can put less pressure on yourself. Reading the original article, which was sent to me by a friend during dedicated, actually put me at ease. It unveiled the ridiculousness behind what this exam has come and made my dedicated study period less of a pressure cooker. Still though, you can set yourself up for the best chance of success by following my recipe. I just wanted to lay the appropriate groundwork and ease tensions first.
When To Start Step One Studying
The first point of contention with respect to studying for Step One is when to begin. I don’t mean when to begin hitting things hard, but when to begin anything at all, no matter how light. The reality is that not a lot of what you learn in your first year of medical school is directly transferable to Step One. Why is this? Well, it is two-fold. First, you are learning how to practice medicine, not how to take a single exam very, very early in your medical career. So, this is a positive thing! Second, first year is much more about building a foundation. At my institution, the courses consisted of anatomy, physiology, biochemistry, neuroscience, microbiology, and pharmacology. You definitely learn a lot about these individual fields, all of which is applicable to your future, however in your second year of medical school, if not your first year if that is how your curriculum is organized, body systems tie all of these relevant components together. The only exception to this microbiology and pharmacology, which are super high-yield stand-alone topics. More on this in a second though.
So, I will concede that there is some, emphasis on some, studying that can be conducted after and/or during your first year of medical school. The problem you will combat though is making sure the material sticks. For instance, if you cross reference content with certain Step One resources, that is great, but the information is certainly going to have evaporated weeks, not to mention months, later. Therefore, you need to employ the magic of spaced repetition. This is the idea that to most efficiently and effectively memorize material you need to see it at increasing intervals. Basically, you are exposed to it right before you are going to forget it again. This is difficult to assess and construct yourself though. For instance, what material do you look at again and at what intervals? Honestly, it is nearly impossible to set this up without the help of an algorithm. That is where Anki comes in. It is a free (did I mention free) flashcard program that incorporates spaced repetition. Essentially, you rate your comfort with each flashcard and it decides when you will see that card again. Obviously this is simplifying things, but I have a video going over how I utilize this program for school purposes, as well as Step One purposes. Yes, this is an overt and shameless plug for Anki, but I truly believe in it because of its ability to optimize your medical school experience. Beyond that it is tweakable to your learning style. For example, if you are very visual, you can throw screen shots on your flashcards seamlessly. This is what I would constantly do with lectures. What is even more magical about Anki is that there are high quality premade decks for download. I discuss this below.
My Resources and Tactics During and After M1 Year
Enough rambling though, right? What did I do during and after M1 year to set myself up for success later on? Initially, I fell victim to the traditional methods. This largely revolves around First Aid. There are only two relevant sections initially, at least in our curriculum I discussed above, following your M1 year: biochemistry and immunology. So, I read these sections. This did not amount to that many pages, perhaps something like 75. However, they are incredibly dense pages haha. First Aid is largely a book of facts. Therefore, passively reading it is not going to allow for things to sink in long-term. I quickly realized this and struggled with how to proceed. Making my own spark notes seemed time consuming and fruitless, as did making my own Anki cards. This is where the Bro deck came in. The Bro deck is essentially First Aid turned into 25,000 high-yield, quality flashcards. Remember, my whole spaced repetition rant? Well, you get the point. The only relevant sections of the bro deck, which I have linked in this video, were biochemistry and immunology. I outlined the nitty gritty of incorporating these into your routine in the Step One Purposeshyperlink. Honestly, this required little effort on my part, perhaps thirty minutes a day to keep up with flashcard reviews, and burned these topics into my memory well before my dedicated study period.
Additionally, remember how I said microbiology and pharmacology were stand-alone, high-yield topics? Well, you have no doubt heard of the company SketchyMedical. If you haven’t you must live in a pineapple under the sea. They animate scenes that tie together characteristics of various bugs and drugs. It is essentially a memory palace. Even months later, largely thanks to Anki, I could visualize every element of every scene and therefore all of the characteristics of the bugs and drugs. The videoI alluded to above also links the Salt and Pepper deck. This deck rapidly gained recognition as the go to microbiology and pharmacology deck. Some devoted individual not only created high yield cards based on the content in sketchy micro and sketchy pharm, but also attached the relevant screen shots from each sketch. They are nothing short of magical. I had either watched the videos previously with class or watched the ones I had skipped over and then threw the relevant cards into my rotation. Again, the details behind this are discussed here. Just as with the bro deck cards, specifically biochemistry and immunology, these scenes and concepts were burned into my memory banks long before dedicated began. In conclusion, the only Step One studying I incorporated after first year was Anki, namely the biochemistry and immunology Bro deck sections and the Salt and Pepper Sketchy deck. This was not a tremendous undertaking, consuming no more than an hour a day, and paid incredible dividends, as I have mentioned numerous times. I have so much love for Anki (if you couldn’t tell)!
Resources I Barely Touched/Didn’t Use After M1 Year
It is very, very easy to get over resourced. Did I mention how we are cash cows? Over resourcing yourself simply means you don’t fully dive into any singular resource and therefore don’t really instill concepts and facts. Moreover, you just stress yourself the hell out. I was cognizant of this trap and therefore excluded a lot of things from my studies.
First I need to mention one thing; don’t forget about class! It is a bit bizarre that I have to remind you of this, but we live in an era of medicine when there are an overwhelming number of quality resources. Additionally, there is no perfect medical school curriculum and there never will be. There is so much information that must be presented to you and so many different ways it can be organized. Not to mention the significant variability in lecturer quality. However, you are more than likely paying a ton of money for your education. Not simply by virtue of this, but also because it will help you moving forward academically and professionally, it is your duty to learn this materially fully. I am all about life hacking though, so I would be remise not to mention some short cuts that will not sacrifice quality.
First, I am sure your medical school records lectures. This is an unbelievable luxury. I would highly encourage double speeding because I doubt that your mind is sophisticated enough to merely absorb a dense lecture auditorily. Yes it provides context, but that context can be garnered by double speeding, or 1.5x or even 1.25x speeding if you so desire. Even more extreme is the notion of not watching the lectures in the first place. I didn’t start doing this until later in second year and upon doing so I wished I had started much earlier. I would immediately go to the power point slides. The clarity of the slides dictated which portions of the lecture I would watch, if any. Moreover, this is where external content resources came in for me. If something was not addressed clearly in the lecture, I could simply cover that concept in First Aid or Pathoma. I firmly believe this is the most efficient way to utilize these resources. They certainly have their place, but are more of reference material in my mind than primary resources. Additionally, the time saved by now watching lecture at normal speed, not to mention actually going to class to observe it live, left plenty of time for external resources without working myself into the ground. This balance is simply not achievable otherwise.
My Resources and Tactics During M2 Year
As I mentioned previously, the body systems of second year build very nicely on your M1 foundation. Moreover, they parallel external resources quite nicely, as these are organized by body system too generally. Once again I felt victim, somewhat, to popular beliefs. These prop up First Aid and Pathoma as the holy grail. Don’t get me wrong, they are valuable accoutrements, but in my mind they are just that. However, I still read through First Aid in conjunction with each organ system. This was certainly a waste of time as I retained nothing. However, I did continue my faithful commitment to the Bro deck. For the nth time, this is detailed in this video. I had actually read through Pathoma the summer after M1 year and didn’t really touch it throughout M2 year. I stupidly purchased the videos and didn’t touch those much either. So, my content studying consisted of continuing to chip away at the Bro deck. This is a big deck, totaling roughly 16k cards. However, working through it incrementally makes it very manageable. My total Anki commitment, including keeping up with the reviews, as that is the point of the program, was no more than an hour a day.
More important than any form of content review is questions. Who cares if you can rattle off all of the symptoms of neurofibromatosis type I if you can’t recognize its presentation or answer particular questions about it in relation to a question stem. Honestly, Step One is largely a critical thinking test. Yes, you need the baseline knowledge, but you need to apply it. Perhaps even more important is thinking critically and making educated, reasonable guesses when you are a bit lost as to what is going on. Mastering being comfortable with this uncomfortable feeling, as well as honing your critical thinking skills is key. Contrary to what a lot of people think, your test taking skills are not static. I describe my journey with the MCAT, ultimately jumping from the 50thto 90thpercentile, and defying this logic. So, you need to be hammering questions throughout second year. Our school mandated a Kaplan purchase by including it in our student fees, but I was very happy with the product. Yes, it is not UWorld, but it exposes you to more questions and primes your reasoning abilities. I did Kaplan questions in conjunction with each organ block, ultimately completing the entire bank before dedicated. This is slightly over 2k questions. I’m not going to lie, it was a time commitment alongside school and Anki, but certainly manageable, especially as I carved out time by limiting my commitment to lecture. What people often fail to realize is that question banks are content review in themselves. The explanations (at least this is true of Kaplan, and obviously true of UWorld) are lengthy, detailing not only why the right answer is right, but also why the wrong answer is wrong. So, I strongly encourage you to buy a question bank beyond UWorld and chip away at it throughout the year. I promise you will not regret it. As for other question banks, I cannot speak to their quality. All I can say is I was happy with Kaplan. In fact, I think it is highly underrated as a supplement throughout M2 year. The reason I did not go with USMLE Rx is that what I read, as well as garnered from talking to people, is that it strongly parallels First Aid. I figured I was getting plenty of First Aid exposure with the Bro deck.
One final note with regards to what I did during M2 year is my utilization of UWorld. There are two schools of thought revolving around UWorld. Some advocate for doing it throughout M2 year with organ systems and then resetting it to tackle again during dedicated. Others say to save it. I would propose a combination. First, there is absolutely no need for two passes. In fact, you undoubtedly will remember questions, rather than concepts, which defeats it value as a study tool. Moreover, when you are exposed to things for the first time it tests your critical thinking chops, which I noted are crucial. However, there are a crap load of questions and this number only continues to rise. There are nearly 2,800 UWorld questions. This makes tackling all of them, while leaving time for other studying and things like sleeping and eating, difficult. Therefore, I would recommend starting to slowly work through it in the spring. I had completed about 20% of UWorld prior to dedicated. Given the fact that I didn’t completely finish it, leaving about 300 questions on the table (more on that later though), I certainly could have done more than this.
Resources I Didn’t Touch During M2 Year
There are really only two things I want to discuss here, including larger premade Anki decks and comprehensive content sources, like Pathoma and Boards and Beyond. With respect to the larger premade Anki decks, the most prominent one that comes to mind is Zanki. While this is no doubt an incredible resource, it is unbelievably overwhelming. It totals something ridiculous like 26k cards. The Bro deck was a commitment, but a manageable commitment that left my sanity intact. Working through this was more than I wanted to bite off and honestly after now taking Step One I really don’t thinking this deck would have prepared me any more thoroughly than the resources I choose.
Similarly, the external content sources, which consist of hundreds of hours of videos, are no doubt fabulous for instilling concepts. However, they are difficult to incorporate on top of the hundreds of hours of lecture you are responsible for learning (yes, this is still the case even if you are not watching lecture or speeding it up). Similarly again, killing myself to incorporate all of this would not have made me any more prepared than the resources I choose and my sanity would have certainly suffered as I would have had little to no time for anything non-medical. In conclusion, I found the Bro deck comprehensive enough, while striking that fine balance of not making me lose my mind. Additionally, I view these external content resources just as I view First Aid and Pathoma, as quality references. If you really need to, watch select videos here and there. Ultimately, time spent with passive studying, like watching videos or reading dense textbooks, is time not spent actively studying, such as with Anki or questions.
There is a significant caveat to this though. I know quite a few people who went all in on these resources, completely blowing off lecture. They would either do a massive premade deck, like Zanki, and/or video series, like Boards and Beyond, and/or core text book, like First Aid or Pathoma, obviously alongside questions, in leu of class. Depending on their nerve, they would never look at class material, merely glance at the slides in the final week of the block, or binge the lectures in that week. This is certainly enough to pass, which is all that matters in the first two years, as well as get the foundation necessary for Step One. This is not the route I choose, as I was happy with my methods, but I would say it is a viable alternative if your goals are to gain a solid foundation prior to dedicated, as well as maintain relatively sane. Image how much time blowing off class would free up.
How Much Time To Spend Studying
This is actually a pretty straight forward question to answer. I would recommend no more than 6 weeks. 6 weeks was what I planned out and honestly, if I was more organized (more on that in a minute), I could have certainly done it in 5. Beyond 6 weeks and I start to question your foundation and study tactics. Not to mention the fact that you will most definitely be burned out, which can seriously impact your performance. As far as your foundation, I am not claiming you should start at a baseline of 230. This requires a serious amount of ingenuity. I am just posturing that you understand the material and have devoted some of it to memory by doing all, some version, or some semblance of what I propose here. This takes a tremendous load and amount of stress off prior to and especially during dedicated studying. Moreover, if you extend your window of studying for much longer, I wonder what your study tactics are. Are they incredibly passive, including watching large amounts of videos and passively reading? Are you learning from your mistakes in question banks properly (more on this in a moment)? Ultimately, I don’t care how much of a superhuman you think you are, you can only grind so hard for so long without consequences. Dedicated studying grinding is different than anything you will have ever done. It is the most drained I have ever been, actually both physically and mentally. So, please don’t push your studying beyond 6 weeks. You can come in with a nice foundation with less effort than you actually think, work efficiently and effectively (more on this to come), and not spin into a burnout.
My Schedule and Resources
Ironically, I had this super pretty schedule down to 5 minute increments that included me being done studying at a reasonable time each day, as well as all of Sunday off. This quickly evaporated haha. Don’t get me wrong, I would actually encourage you do this, as it gives you a sense for how you want to structure your days, as well as how disciplined you need to be to get through content. However, don’t be surprised when you need to adapt it.
You already know how I feel about questions and their importance, so obviously UWorld was at the core of my studying. For the first two weeks, I was able to rise at 6 am, however as I grew more tired and burned out this crept up to 8 am during my last week of studying. Without fail though, the first five weeks consisted of two UWorld blocks in the morning. I would do a block and then review it and rinse and repeat. From the very beginning, I started with random timed blocks. I really believe this is the best way to approach UWorld, yes, even from the very beginning. Again, if you follow the recipe outlined here, you are certainly prepared to approach things from this angle (I mean you will have busted out a whole question bank already). Moreover, it orients you to differing content coming at you constantly, as well as teaches you to think critically and make educated guesses, which you unfortunately will do more often than you would like on the real deal. As far as the review of the blocks. Initially I spent about two hours per block, but this slowly dwindled down to about an hour per block. The explanations are incredible. They truly have everything you need to know in them, but this means they can be lengthy. I would rarely ever reread any of the questions, instead jumping right to the explanation. Additionally, you get a nice synopsis of why the wrong answers are wrong. There is really no need to consult any other resources while reviewing UWorld blocks, as all of the pertinent information, and so much more, is right there. As concepts repeated themselves, I would skim them, honing in on whatever I wanted a refreshing on or hadn’t seen before. Again, there were two things I wanted to divulge from every question: why is the right answer right and why are the wrong answers wrong. Zeroing in on this when concepts repeated allowed me to get through reviewing blocks much more effectively and efficiently. After all, I don’t need to read about TB for the millionth time if I continue to get questions about it right. To instill things long-term, I made Anki cards from my incorrects, which did not contain an overbearing amount of information. I had simple, pointed questions that targeted what misstep I had on that particular question. Supplementary information or pictures can be added for reference too, but you want to be able to get through your reviews quickly and not get too bogged down by this.
While questions are the crux of dedicated studying, there is some content review to be done. After all, you need a refresher on quite a bit of stuff haha. Just prior to dedicated, I stopped reviewing the Bro deck, as well as the Salt and Pepper deck. I had gotten through them in their entirety and spent just as much time with reviews, so I knew the material very well at this point. I wanted my core content studying resource to be Sketchy Path. I watched the videos throughout M2 year, but didn’t take notes or make Anki cards from them. Basically, I wanted to familiarize myself with the scenes, so I didn’t have to watch any of them during dedicated. As I have stated countless times, videos are a huge time sink. Moreover, I had gotten my hands on a pdf with pictures of the scenes and detailed explanations (reach out to me if you are interested in obtaining a copy of this;). I intended to review simply this. This is what I did in the first week, spending the afternoons and evenings doing so, however I quickly realized that things were not sticking. This was too passive. So, I turned to old reliable: Anki. However, making my own cards was time consuming. That is when I stumbled upon my savior: the Conaanaa deck. Similar to the Salt and Pepper deck, this takes relevant screen shots from Sketchy Path. Even if you are not a fan of visual learning, Sketchy Path is comprehensive in that it covers virtually everything you need to know for Step One, apart from biochemistry and immunology. Additionally, it explains pathology in a very simple and easy to follow up format. So, I split the Conaana deck into its respective chapters and videos, similar to how I split the Bro deck and Salt and Pepper deck. My approach this time was different than previously though. Given my short time frame and the cramming that happens in dedicated, I simply went through each video’s cards twice. I rolled through all the cards in order and then did the same thing one more time. On the second run, I took notes in a notebook on what I deemed high-yield. There is no rhyme or reason to doing this, as it was personal to my weaknesses and largely consisted of the things I wanted categorized well in my head, such as anemias, leukemias, and lymphomas. Then, the final bit of content studying I did was to look through this notebook in my last few days of studying. It was basically the Anki cards written out, which made the studying active, rather than passive. Moreover, I would close my eyes and picture the scene, trying to sear it into my memory. This really helped catalogue tricky items, like the things I mentioned above. Because I ultimately landed on a concise and efficient method for content studying, I ran through everything twice and then what I deemed high-yield a third time. This is certainly not the norm, as most people are bogged down with heavy content resources and barely get through everything once, if that. It is worth mentioning again that question banks, especially UWorld, double as content review. You get exposed to virtually everything in the question bank, especially if you add on a second prior to dedicated. Because I was anxious about this, I flipped through First Aid and read about anything that I felt was not covered by either of these sources. Surprise, I read next to nothing and definitely wasted my time doing this. So, it is okay and in fact encouraged (at least by me haha) not to utilize these traditional, dense resources that can bog you down and lead to ineffective studying habits. In retrospect, I wish I had discovered the Conaanaa deck earlier, as I would have replaced the Bro deck, with the exception of biochemistry and immunology, with this. Honestly, if you mature this deck prior to dedicated, which is totally manageable, as it is only about 3,300 cards, you will annihilate Step One. I am that confident in it.
The last thing to touch upon is practice exams. I took one at the end of each week for the first five weeks and then threw in the Free 120 and UWorld 2 in the final week. This was a good number. Any more and I would have encroached on UWorld questions and Sketchy Path content review, not to mention have added unnecessary burnout. As far as what practice tests to include, you want a mix of the NBMEs, old and new, and obviously UWorld 1 and 2 and the Free 120. The NBMEs are stylistically different, providing less information and requiring a bit more educated guessing, albeit more straight forward educated guessing than UWorld. In addition, they have more weird, WTF questions that no amount of studying can prepare you for. You need to get exposed to these so you are not thrown for a loop on test day. The older NBMEs are more straight forward in my opinion, however the curves can be brutal, so take that into consideration (there are reddit threads that shed insight into this, but don’t spend too much time in that cesspool haha). For instance, on NBME 16, I believe I got about 85% of the questions right, but this only amounted to a 225. That is a respectable score, I just thought it was a ridiculous percentage to land at that. The newer NBMEs have a less harsh, but still pretty steep curve and definitely are more bizarre. Again, you want and need exposure to all types of question styles. The UWorld assessments overpredict, or at least that is the word on the street. I can’t really speak to this until my score comes back. The Free 120 is pretty straight forward and a nice confidence booster before the real deal. More importantly though, you can take this at a Prometric testing center, which I would highly, highly recommend. It acclimates you to the environment and gets rid of any potential surprises. For example, I was able to time out how long breaks take since you need to sign out and in, getting wanded in between. Ultimately, my real exam felt like a mix of all of these, so I was glad I had a well-rounded exposure to different question styles. I really can’t say more than this though, as it feels like a bit of a blur in retrospect. I don’t know how people recall (and sadly stress) about questions or write detailed reports of what the exam felt like. Don’t let any of this stress you out though because there is most certainly recall bias at play. Someone who feels like them bombed it (assuming they prepared appropriately and were scoring in their desired range) likely fixates on a few questions th