Step 1 Experience
Between April 1st to May 25th, I experienced a new level of stress and anxiety that no amount of weighted blanket or plush toys was able to alleviate. (See picture below for proof lol).
For those who are unfamiliar, at many medical schools, students take USMLE Step 1 after the first two years of medical school. The concepts on this board exam cover the foundations of the sciences required to understand and practice clinical medicine.
In theory, most of this type of content is covered during the didactic years of medical school (classroom learning). The reality of medical school is that the first two years are not going to cover all the information. However, the expectation is to learn as much of the content as possible.
The Exam
USMLE Step 1 stands for United States Licensing Examination. It is one of the first board exams taken by medical students in the United States. This exam was changed from a scoring system to Pass/Fail. This change was created in order to make the lives of medical students a little less stressful and to help them focus more on learning. Even with this change, the exam is still very difficult.
The exam itself is 7 sections long, and each section contains up to 40 questions. These questions are multiple choice. To my surprise, the exam also includes audio questions. For example, the exam may describe a clinical scenario of a patient with a cardiac issue. They will then ask you to listen to the audio through headphones and ask you to identify the murmur. These questions were quite a shock to me because I was under the impression that all the questions were just going to be written text.
The material that is covered on this exam is linked here: https://www.usmle.org/prepare-your-exam/step-1-materials/step-1-content-outline-and-specifications
My Experience
This exam was excruciatingly difficult for me to study. I spent most of my time studying, and saw very little improvement.
To begin, here is what my process looked like from the beginning of March when I was still in my second year of school.
March 11th: CBSE (Comprehensive Basic Sciences Examination)
April 1st: Start of Dedicated Step 1 Study Period
May 12th: Initial Step 1 Date
May 15th: Rescheduled Step 1 Date
May 25th: Second Rescheduled Step 1 Date
May 30th: Third Year Orientation.
My school gave us 6 weeks to study for Step 1 so my initial date was scheduled for May 12th. I was very excited about this date because it meant I would be able to attend my cousin’s wedding and attend the ACOG conference that was in Baltimore, MD. Unfortunately, I ended up not being able to attend either because I pushed my exam back by two weeks. I did not purchase any plane tickets or book hotel rooms for the conference so I was happy that I did not waste a lot of time or money when I didn’t end up going.
The process of preparing and gauging my readiness for Step 1 began with the CBSE exam. CBSE stands for Comprehensive Basic Sciences Examination. This exam is from the NBME (National Board of Medical Examiners) and was purchased and hosted by my school to help gauge where each of us were before the dedicated study period (known as dedicated). My school informed us that we would not be scoring well and that they expected that so we should not freak out. Truthfully, I knew whatever results I got meant that I would not be ready for the exam.
The results of this exam gave a percentile score and based on that number, it tells how likely one would pass if they took the real exam in the following week. My score for that told me that I would not pass if I took the exam within the week. I knew that already. The score wasn’t that helpful to be honest.
This CBSE exam was helpful in simulating part of the length of the exam, the types of questions, and the length of those questions. For my class, we were unlucky and had our Neurology and Psychiatry exam the day prior. It was a bit brutal. The one question type I was not prepared for were the communication questions between both the neurology exam and the CBSE.
The end of the school year was brutal and on top of that stress, I chose to move out into a new apartment. Around April 2nd, I moved out so it was right at the beginning of the dedicated time. I will be forever grateful for my family because the move was brutal but we somehow did it. April also happens to be when my brother and I have birthdays, so just from all of that, I was cutting a lot of my study time short. There was one family incident that occurred and it really threw me off for one week. I had decided to stay home that week, but it ended up being distracting. It was an unplanned situation so there was no way for me to know that would happen.
I was confident that I would be able to use the 6 weeks as my school predicted even with all those life events. My plan was to use the Uworld practice exams, utilize the two vouchers I had for CBSSAs, and take the Free 120 about 3-4 days before my actual Step date.
The first CBSSA score destroyed my confidence. I did not improve from my Uworld practice exams, and it was not a passing score. I cried and ate my feelings away with Taco Bell. I hoped that would be the only time, but I ended up doing that for practically every CBSSA I took.
At this point, I reached out to the associate dean of Student Affairs at my school. He scheduled a Zoom meeting for a walk through of the exam. When I read that email, I thought “dang, I must be real dumb” but in reality, he just wanted to see what my thought processes were and if there was a content deficit or if I was practicing poor test taking skills.
His confidence in me was greater than my confidence in myself. He suggested I take a week longer because it sounded like it was messing with my head that I felt like I missed a lot of study time. It turns out rescheduling is pretty difficult because there aren’t many exams offered. I was looking between areas near my school and my parents’ house so between four to five states. To move the exam it costs $100. The options that were available were over 100 to 200 miles from where I lived at school.
I ended up rescheduling to May 15th, and I convinced myself that I really could do it within 3 days. I did have one friend tell me to keep looking and reschedule when something did open up, but my anxiety was too much. I do wish I listened to him though.
I didn’t pass the second CBSSA, so I panicked. The tears and self-doubt were present for a few hours. At one point I remember logging in at 11:00 p.m. and rejoicing because there was a seat available on May 25th at my original location. I rescheduled the exam again. in case you weren’t keeping track, that is $200 on top of the original $645 to take the exam. At some point, I decided to calculate how much money I had spent on this exam, not including medical school. With all of the resources such as Pathoma and Uworld and the costs of scheduling and rescheduling, I calculated around $1500. (I will go through resources at the end of this blog post. )
The next two weeks were filled with the same daily life. I know I posted an Instagram reel about what I did in a day and it really was that. I would wake up and as the weeks progressed I was waking up later and later which was not helpful for the day of the exam. I would wake up, brush my teeth, make my coffee and breakfast, and then I would sit down to review the previous day’s wrong and right answers.
After I did that, I would do some content review, some more Uworld blocks, and then take a break. After my break I would review those wrong questions and do more content review. At some point, I would make sure I ate lunch. If I felt like it, I would try to schedule a workout. Depending on what else needed to be done I would try to take care of my chores. Other than that, all I did was questions and content review endlessly.
My mental health severely suffered during dedicated. I spent most of my time living in the past even though I knew that couldn’t change. I spent countless hours being upset about the required group work that my school enforced. “5 hours every week for 8 months…just for PBL” is all I could think about. I have strong feelings about PBL, but that is another post..potentially after I graduate.
The worst part was seeing when my classmates were done taking their exams. I was envious and very upset that I could not take my vacation. I wanted to travel and spend time with my family. I didn’t want to be sitting in my room answering more Uworld questions. It felt horrible. I was going to be taking my exam 5 days before our orientation so there wasn’t much time left for a break. It helped me to know that my friends were also in the same boat, but I still wished that I was like my other classmates. I wondered what I did wrong and why I wasn’t as smart as them. I felt very inadequate.
Social media truly made matters worse while seeing people who were not in medical school. Many people were posting about their milestones, and I just felt sad because I was doing the same thing everyday and struggling to see progress. I did know that I was in the place I needed to be for my journey, but those feelings are still difficult to face and process.
That being said, Step 1 is just one step in this process. (Haha very funny right? This joke was made many times.)
There was one moment when my dad told me “This is just one exam and you just have to do it.”
He was not expecting this but, I went off about how this is not just one exam. Once this exam is over, I would be starting in the hospitals and dealing with abuse from people above me. In between the shifts at the hospital, there would be more exams. Then, after a full year of doing that, I would have to study for another board exam called Step 2. After taking Step 2, I would be preparing my application for residency and then interviewing for residency.
I told my dad “This is never ending and it sucks.”
His response was “no one said this was easy.”
Despite the entire process of studying being horrible, I was thankful for my friends and other medical students in the social media world. I didn’t feel alone when I talked to other people about my experiences because they felt the same way. It validated my feelings when others described how difficult the studying process was for them.
When I got to school for orientation, it turned out other students felt similarly but were unable to find other classmates who were in the same boat. One student was shocked to hear my experience because he related to it and thought he was the only one.
If it’s possible, try talking to classmates or other medical students on social media about your experiences. I know it’s difficult because there are some classmates and people who will not struggle and may not empathize. It’s also tricky because some people will play the comparison game and it might mess with your head.
Exam Day
One of my biggest issues during Step 1 studying was that I would pick an answer, think about it and change my answer because I couldn’t understand or figure out why I picked that answer. Usually, my gut instinct was the right answer and then I would choose a different answer after convincing myself that I was wrong. This habit was and still is very difficult to break. If you are a medical student, please do not develop this habit. Second guessing yourself is just not it especially when you get to third year when there are preceptors who want to disrupt your confidence. Knowing this, on exam day, I had to keep telling myself “first gut answer, first gut answer.”
On the day of my exam, I was very, very anxious. Unfortunately, my exam started 30 minutes later than the start time. The start time was scheduled for 9:00 a.m. and I got there around 8:30 a.m. My sister dropped me off after I prayed and got my blessings from my mom and my dad. I had to sit there and wait. It was a little difficult, but one woman chatted me up. We talked until it was time for my exam. I am grateful for her because it helped ease my anxiety even though the entire time we talked, I kept repeating some statistics formulas.
To paint a better picture of the Prometrics experience, there are multiple different exams happening at the same time. There were some students taking USMLE Step 2 that day, and many other people taking different licensing exams.
At one point I came out and one of the Prometrics workers asked me if the exam was done and I said “nope only half of it is done”.
He asked “how much longer is this exam?”
I said “Another 4 hours”
He looked at me in shock.
It went on like that for every single break I took.
After the exam, I had nightmares about those questions for weeks after the exam. My classmates told me the same happened to them. I didn’t even know when the score was coming out. One of my friends told me the Saturday before the score came out. For context, the scores are always released on a Wednesday.
Now I thought a lot about how I wish I could go back in time and warn myself what was to come. But there is no way to do that, so I wanted to give future medical students advice instead. As always, you should take this advice with a grain of salt.
Overall
Wild, right??
Never did I think I would utter the words “I should drop out” and Step 1 did. It has been my dream for years to become a physician, but the anxiety and stress was more than I imagined.
Now that I’ve gone through some of the things that I struggled with, I will say there was a big, bright light at the end of this dark, dark tunnel.
I passed!
I am very grateful for the love and support that I received from all my friends and family during this time. It was very difficult. I didn’t know if I was going to pass. I was very scared. What would happen if I didn’t? I would have posted it on this account to let everyone know what my experience was because I believe transparency is important but I would still feel embarrassed at the thought not passing. I am grateful that I passed. I am worried about the next exam. However, I know my strengths and my weaknesses and I am better set up for the next exam.
Here is a picture of the snacks my siblings bought me last minute the night before my exam. Their support means the world to me.
I did not pass a single practice exam. All of my practice exams were scores below 60%. To provide context, my school suggested that to be scoring consistently around 60% or higher to feel comfortable taking the exam. On Reddit, the advice is to be scoring 70% or higher. (You see my problem here?)
I scored a 54% as my highest on my last CBSSA and I knew I had to take the exam. I was so tired and fed up with it. I wanted my life back. When I talked to the associate dean of student affairs, he asked me “how do you know you’re ready?” and I said “I know I’m ready because I didn’t have a mental breakdown”.
He laughed really hard, but it was true.
At this point, I had hoped that I would score better on the Free 120 questions that were available. I had decided to take them 4 days before my May 25th day as was advised by my school…and I unfortunately scored a 57%. That didn’t really help my confidence, but I knew I had to take the exam.
Resources
The actual studying for Step 1 was a bit frustrating. I had deficits in many areas from different life events happening during the first two years. For instance, I was sick for two weeks during the heart portion of the Heart-Lung-Kidney block. That means I basically never got a solid foundation in heart pathology until I focused on it during Step 1.
The other issue was seeing information for the first time. At my school, the courses are integrated which is great for learning purposes. However, I felt like I struggled heavily with pharmacology because we did not have a dedicated pharmacology class. It might also have to do with my own deficits in specific areas of medicine.
For resources, I use Uworld, Pathoma, Boards and Beyond, lectures, and textbooks such as the Robbins textbook and the Costanzo physiology textbook. I would also review books such as Crush step and First Aid. In addition, I use the practice exams that were from the NBME. These practice exams were called CBSSA which stood for Comprehensive Basic Science and Self-Assessment. These practice exams for former NBME exams that were retired.
Many of the following are affiliate links to Amazon.
If I could go back in time this is what I would tell myself:
Start using Crush Step from Day 1 of medical school. Crush Step is an incredible review book with a podcast! I didn’t start listening to the podcast until a week or two before my exam. It’s essentially medical students who wrote the chapters reading the chapters. I found it helpful when driving back home for my exam because I was reviewing some content by listening.
Crush Step is lesser known now. I’m not sure why. The associate dean from above suggested it when he first started discussing Step 1 with us. He did not join my medical school until half way through my first year, and I wish he was there during our M1 orientation because I would’ve been using that book immediately.
Crush Step: I like this book because it has relevant content, and is written more like a textbook. I found that First Aid and some BRS books were difficult for me to read for long periods of time because they were more like bullet point notes. This content review book is also very straightforward with the information.
Some people hate paragraphs and enjoy the bullet notes. This is entirely a preference.
Spotify Link Crush Step Podcast: https://open.spotify.com/show/1zRYlByLLzgpXMkeUPQKW1?si=21c2ee6af3174a82
First Aid: This book is a must for medical students. I did not rely on it heavily like my classmates. I did love it just as much as they did though because if there was a disease and I needed quick information, I could look at it. I also enjoyed their pharmacology pages, and their diagrams are great. There are many memory aids through this book. Some are useful while others are just weird.
In addition to the Crush Step book, I wish I stuck to textbook reading. I know that I gave myself the freedom to figure out how I needed to learn from medical school. I think all people should do that, but I found that textbook learning was the best for me. I should have been reading the textbook for one reason and one reason only. That reason is that Step 1 tests heavily on the mechanisms of actions. That means you need to know the specific details of different enzymes and different processes as well as understanding the general clinical picture.
What I noticed from my CBSE was that Step 1 questions will give you the clinical picture in this question stem itself. For instance, the question would probably describe a heart attack. It would literally tell you that the patient was experiencing a myocardial infarction. It would then ask what you would see on histopathology and then give you four specific examples based off of the timeline to choose from. That information is hard to remember when there’s a lot of different details out there. I thought I would just need to know how to treat a myocardial infarction for Step 1 or recognize what it was…but that is not the case.
Textbooks
Costanzo Textbook: This textbook was one of the few options we had during first year. I really liked it and found myself reading it to review physiology during dedicated. https://www.amazon.com/Physiology-Linda-S-Costanzo-PhD/dp/0323478816?crid=2E9WUN4NF36I7&keywords=costanzo+physiology&qid=1688766419&sprefix=costanzo+%2Caps%2C101&sr=8-2&linkCode=ll1&tag=thecuriousm06-20&linkId=d3414803369058d6656b006f355e1de9&language=en_US&ref_=as_li_ss_tl
Robbins Textbook: This textbook is highly recommended for pathology. It was one of the books we needed for school so I bought a physical copy and it was very useful. https://www.amazon.com/Robbins-Cotran-Pathologic-Diseas-Pathology/dp/032353113X?crid=192MUJ0GW8CMA&keywords=robbins+and+cotran+pathologic+basis+of+disease&qid=1688063344&sprefix=robbins+%2Caps%2C516&sr=8-1&ufe=app_do%3Aamzn1.fos.f5122f16-c3e8-4386-bf32-63e904010ad0&linkCode=ll1&tag=thecuriousm06-20&linkId=9478b406d83119c021e21124c26beeb8&language=en_US&ref_=as_li_ss_tl
Boards and Beyond was provided by my school and I really liked it from my second year on. This resource was great because they’re like mini-lessons for every topic. The videos go over the board relevant content. There are powerpoints that can be downloaded and there are quizzes for each lesson.
Boards and Beyond: https://www.boardsbeyond.com/homepage
Pathoma is another book but with videos. I was hesitant to add this early on in my second year because I felt overwhelmed with all the resources. However, I really enjoyed it later on and it was super helpful to understanding pathology especially when I didn’t have time to read the Robbins textbook. I do recommend starting it as soon as histopathology is introduced.
Link to Pathoma website: https://www.pathoma.com/features-and-pricing
Question Banks
The two question banks in question are Uworld and Amboss. I cannot say anything about Amboss for Step 1 studying because I did not use it. I will discuss my Uworld experience. To provide some context, I used Uworld for MCAT studying so I really liked the platform. I was prepared to use it, and it was the question bank my classmates were able to get a group discount for as my school did not purchase a question bank for us as an institution.
Truthfully, I think I wish someone told me to start practice questions from either of these question banks in the first week of medical school. I know the questions would’ve been challenging because I would not know the clinical pictures, but it would’ve given me a chance to start understanding how to better study for medical school. I remember I was trying really hard to understand the change between undergraduate studying and medical school studying and it didn’t click until second year.
It is 100% okay if you don’t buy a question bank until later on in medical school. This recommendation only comes from my understanding of my learning process. At the bare minimum, Uworld should be used in the second year as soon as possible.
Uworld
Uworld as a platform is great because it replicates the NBME view and it provides you a method to take notes on the side and create flashcards. It has two practice exams in the Step 1 6 month subscription. Those are only valid for two weeks at a time. I was under the impression that I would use all of Uworld in 6 weeks; that was a wrong assumption.
It cost me about $435 for a 6 month subscription with the discount.I did start the Uworld questions sometime around December and January. However, I found it very difficult to do the questions and review them properly during the school year because I was doing older topics. I wish I did them concurrently with the block exams, but I was worried I would run out (you won’t and even if you do, you can reset them).
Now onto the issues that I experienced during my dedicated time. The first thing I noticed is that I did have a deficit in a lot of different areas. At the advice of my best friend, I decided to do two organ systems a day. I would do 40 question blocks of each organ system throughout the day. The first thing I would do is the questions and then I would take a break. After my break, I would do content review and review the questions I got wrong. The hardest part about studying is reviewing the questions because you have to review the questions you got right and wrong.
This aspect of Uworld is where it was a little bit difficult. The Uworld answers would basically go through what it thought was best and it would bring up different topics but it wouldn’t go into detail of what those topics are. For instance if I had a question about chicken pox, it would explain the chickenpox answer and then it would also explain the other diseases that were options. However, it wouldn’t go into a lot of details about the diseases so if I couldn’t remember what CMV was then I would have to go look it up and remind myself what it was which could take some time.
The Uworld questions themselves are hard because they are trying to train you to distinguish answers between two very similar presentations. They are well written but definitely difficult (and discouraging).
The other difficulty is that there is no way to ensure you see the high yield information. That was part of why I liked my friend’s advice for organ systems. However, at one point I switched over to random to try to cover more ground and it’s just difficult. The only way to ensure you see every possible question topic is by doing it earlier and finishing all of it. I only finished 48% so I did not see every possible question topic.
Do NOT use Uworld to gauge progress. It is a learning tool because of how difficult and specific the questions are. Use the NBME exams to gauge progress and readiness.
Practice Exams
The official NBME practice exams should be used as the preparedness measuring stick. My school suggested scoring solidly around 60% to feel confident on passing Step 1. Other people, such as those on Reddit, suggest scoring solidly around 70%.
As a reminder, my highest score on a CBSSA was a 54%, the NBME dashboard told me that I had a 70% chance of passing Step 1 if I took it. In the end, it is up to you and your readiness. I do recommend speaking with someone at your school if these are concerns you have. It was very useful for me.
As of July 7th, 2023, these exams are $60 each. There are a few bundles available to think about how many exams you want to take. Your school may provide a voucher for one or a few. It also seems as though there are no practice exams that mimic the full 8 hour day. I thought I would be ready for that length because of my MCAT days but I was exhausted by the 4th section.
CBSSA: Comprehensive Basic Sciences Self-Assessments https://www.nbme.org/examinees/nbme-self-assessments/comprehensive-basic-science-self-assessment
I hope this post was helpful! Let me know in the comments what you think.
