Welcome to Hell

Introduction First off, take a deep breath. This summer will be the worst summer of all time, but youll probably end it being the smartest youll ever be. All youve got to do is make it through and try to maintain some semblance of sanity. The good news is that it goes by pretty quick, and youll never have to work this hard again. Ever. The other piece of good news is that, contrary to what some people may have you believe, you dont have to go buy 15 textbooks and memorize everything under the sun. Now before I get started let me begin with a little disclaimer. This is probably not going to be the most politically correct guide you will receive. I have got a LOT of beef with the way people tell you to study for Step 1, and all of that rage has culminated into this document. Although I appreciate the study guides that were posted out on studentdoctor.net (dont visit that site unless you want to hear what people with absurdly elevated sphincter tone have to say) and sent to us by previous classes, I dont think they represent the only way to study for this exam. Those guides focus on setting a strict schedule and reading through an individual reference text for every single topic. Thats total horse shit. I started off doing things this way, but about a week in decided there was no way on Gods green earth (youll understand when you start listening to Goljan) that I would be able to memorize all the material in these books. So I threw my schedule out the window and just winged it. Believe you me, there is more than one way to skin a cat and Step 1 is no exception. I consider myself to be of barely average intelligence and I literally had forgotten EVERYTHING from the first 1.5 years of med school by the time I started studying. I came from an engineering background and was taught to understand things and problem solve, not to memorize. This guide will probably be most useful for like-minded individuals, although I think this strategy could work for all and is really the only way to properly LEARN stuff. If there is a single piece of advice I can give, its to make sure that you are understanding things as you study them. If you see a sideeffect or associated syndrome, do a little digging and figure out WHY. I garron-damn-tee that you will remember the information this way. Our exams in the first two years pissed me off so much because they required you to memorize everything and understand nothing. You could probably get away with that on step one, but unless you have a photographic memory or are capable of memorizing every single association for every single syndrome, its an exercise in futility. With all of this being said, I really do hope that this guide helps to RELIEVE some of your stress and serves as a good starting point for your forthcoming adventure. However, I take no responsibility if you use it, fail step one, and end up as a dairy farmer in Papa New Guinea. In fact with ObamaCare, its probably not such a bad idea. Ok now that Im done with my rant, Ill hop off my high horse and get down to business. Schedule and Timing I studied for 7 weeks and 3 days, which was 1 week and 3 days too long. The first rule of step one is: DO NOT STUDY MORE THAN SIX WEEKS. The second rule of step one is: DO NOT STUDY MORE THAN SIX WEEKS. And the third rule of step one is: DO NOT UNDER ANY CONCEIVABLE CIRCUMSTANCES STUDY. MORE. THAN. SIX. WEEKS. Several people had told me the same thing, but me being the stubborn asshole that I am decided that this rule didnt apply to me and I could use the extra study time. Big mistake. By week 7 I wanted to blow my brains out and was just trying not to hemorrhage out everything I knew. In fact, I was so burnt out that by the time I actually took the fucking thing I didnt even care anymore, I just wanted oh-sobadly to be finished.

Here is the kicker though: for the 6 weeks that you do study you will be working from about 9am to midnight every single day, weekends included. I used to take a short break for lunch or mid afternoon, but even then I would do flashcards or questions. I normally woke up and got to the library around 930am, left at 930pm, and finished out my night at home doing questions. Id also recommend studying with a couple of friends so you can stand up, walk around, and chit chat every once in a while to stay sane. All in all, out of those 15 hours each day, I probably had 12 hours of productive studying. Weekends I stayed at home for a change of scenery and to be a little more relaxed, and studied about 9am to 10pm. My theory behind studying this way is that step one involves large volumes of information, and if you spread your acquirement of this information over longer periods of time (like 7.5 weeks, but only studying 10-12 hours a day) you will begin to forget the things you studied in the beginning of the summer. This is exactly what happened to me, and I ended up doing all of micro and biochem twice: once in the beginning of summer and once at the end. STUPID. Do not do this. As far as devising a schedule, I went by organ systems for all of physiology, pathology, anatomy, pharm, and embryology. The test is all integrated now so it doesnt make any sense to study these topics individually. Biochemistry, microbiology, genetics, basic path, and autonomic pharmacology were studied separately on their own. Here is a very rough idea of how I spread my time, in no particular order: Microbiology and Antimicrobials: 3 days Biochem: 4 days Basic Path: 1 day Autonomic Pharm: 1 day Immunology: 1-2 days Genetics: 1 day Behavioral: 2 days 10 Organ Systems (as per First Aid) including the physiology, embryology, anatomy, pathophysiology and pharmacology: 2-3 days per block Im sure some of you have already added those days up and are thinking SHIT THATS MORE THAN 42 DAYS. I know. Thats why its very rough, and your schedule will shift and change according to your needs. You will spend more time studying things you are weak on and less time studying things you are good at. I also know that this schedule doesnt leave any time for review, but keep in mind review will be included in the form of questions and Goljan. More on that later. In terms of order of these things, I would start the summer off with the topics that you have completely forgotten (which for me was biochem and micro) because until you go back and review it, you will be wasting your practice questions by blindly guessing at answers and trying to learn the topics piecemeal by reading the explanations. Not a very efficient use of time. The Three Pillars of Step One Goljan: The man is my idol. He is also a national arm wrestling champion and could kick your ass to kingdom come if you got in his way. He is also fucking hilarious and you will never be bored listening to him. He teaches the material the way it should have been taught to us in our first two years sequentially and logically. I think the most shining example of this is his 8 hours of hematology. He begins with the very basics of anemia, the various types, ways to categorize disorders, and then moves forward from there. He will explain to you the WHY, not just the what of diseases. After getting through his lectures the first couple of times (and I would go ahead and start listening now), you will begin to hear his voice in your head as you do practice questions. Here is how I used this resource: Every morning when I woke up, before getting out of bed, I popped in my headphones and started listening to his lecture wherever I had left off. There is a

feature in iTunes that allows you to resume playback on your iPod from where you left off, so ask one of your nerdy friends to show you. I also listened to him while I was in the shower, making breakfast, eating lunch, driving to school, taking a dump, and running from the police. You will get through at least an hour of lecture each day this way, just by listening passively. But heres the golden ticket if you really want to make full use of his lectures you need to get the transcripts. Someone out there took his audio files and actually typed out his lectures, which is pretty much the best thing since sliced bread. When I started out any organ system or was doing the first 8 hours of basic path, I would make it a point to sit down with his transcripts in front of me and read along as I listened, underlining and jotting notes. By the second time through I was listening at 1.5-2x speed and glazing over sections I felt comfortable with. Studying it this way helps a ton because you will be sure not to miss anything and can easily go back and review something you didnt quite get. Simply listening to Goljan passively is a huge waste of this resource and you should get the transcripts and read along to take full advantage. On a side note, Goljan LOVES to talk about most common cause (MCC) of shit. I didnt bother trying to memorize the MCC of anything, mainly because I suck at memorizing. It may give you a starting point for some questions, but there are more than enough clues in every question to figure out whats going on without memorizing the MCC for everything. USMLEWorld: Tied with Goljan for awesomeness. Do not buy Kaplan unless you have $300 to waste, in which case you should just give it to me so I can get myself a hooker. Seriously, Kaplan questions are WAY too focused on minutia and dont require you to understand anything. USMLEWorld is the opposite someone once said doing 50 UWorld questions will give you a headache bigger than the most epic of epic nights you had in college, and they were right. The questions are long, tricky, and force you to think. But as you are thinking, you are integrating all that crap youve been learning and solidifying it by applying it. The explanations are excellent and cover all the wrong answers very thoroughly, so read them even when you get the questions right. Uworld will be the best way to figure out what you understand and dont understand, and things you are consistently missing should be reviewed through Goljan, Rapid Review, and/or FA. There are algorithms out there for taking your percentage correct on UWorld and converting it to a board score. Im not sure how accurate they are, mine was kind of in the ballpark. But by the last few weeks if you are getting in the 70% range you should be pretty good. Do not be disheartened if you start out in the 50% range. There are around 2000 questions total, and I would do 50-75 questions a day, increasing the number as it gets closer to test day. They are very good to do when you are sick of reading or need a change of pace. Each day, half of the questions I did would be only on the subject that I was covering that day so I could solidify what I had studied. The other half would be derived from a cumulative bank of what I had studied to that point. To me it made no sense to do questions covering topics I had not yet studied, so thats why I recommend doing the stuff you are weakest in at the beginning. Once you finish the question bank (and you BETTER finish), go back and do the questions you got wrong. Also, do not waste your time with the UWorld graded practice exams that they sell on the website. They consistently over predict actual scores by about 10-15 points, no joke. The only real way to see where you are is to take a practice NBME. More on that later. First Aid: Ahhhh what can ya say about a pal like FA? You have to know what its good for and what its not good for. Its not good for pathophysiology and disease processes of organ systems the actual meat of the test. The reason is the same as what Ive been getting at reading through FA for pathophys will simply give you a list of word associations and acronyms for remembering shit, but do nothing to actually make you understand it. Unfortunately, on step one there are NO knee-jerk word association questions (pretty much the exact opposite of our first two years), so this material will have to be studied in a different way, which Ill discuss a bit later. But what FA is good for is all the other stuff: embryology, microbiology, biochemistry,

pharmacology, anatomy, behavioral, and genetics. As I was studying, I would make notes inside my first aid in the appropriate section so I could refer back to them later. However, the last week before my exam I tried to go back and reread the whole damn book and had a cataclysmic nervous breakdown because I felt like I had forgotten everything. Fear not, if you keep doing practice questions you can rest assured the information is tucked up there. Honestly, I am pretty sure that if you just used these three sources (FA, Goljan, and Uworld) you can be guaranteed a 240-250. They are that good. Use them wisely. Never stop listening to Goljan and never, ever stop doing questions. The rest of the shit Anatomy: The anatomy in first aid at the beginning of each organ system is sufficient and well laid out. Dont bother using anything else. The only exception would be for neuroanatomy. If you are a little rough around the edges, pick up the HY Neuro (or really any neuro book) and just review all the ascending and descending tracts. FA has them kind of listed, but like I mentioned earlier there are no explanations. Knowing how the tracts go up and down and where they cross will make all you spinal cord questions a lot easier. Dont bother with any of the other shit in HY neuro, Uworld will fill in any gaps in FA. Embryology: FA is more than enough, its unfortunately rote memorization here. Know your pouches, germ layer derivatives, and GU system well. If you really feel like understanding how everything develops then read HY embryology, otherwise dont bother. And if you cant memorize all that shit, dont fret. Its pretty low yield, meaning there are not a lot of questions. By the end of summer I had kind of given up and just took my chances. My exam was also very penis heavy. Hmm Embryology is actually a good example of a very easy way to get bogged down while studying. There is lots of crap to memorize, none of it makes any goddamn sense, and none of it requires you to think. Some of the people I know who are gifted in the memorization department did sit and learn all of this, but my theory is that Step 1 doesnt care too much for these types of questions. They are much more interested in seeing how you think, not how you regurgitate. When it came to topics like these where there was just wayyyyy too much shit to know, I read over it, relied on practice questions, and just told myself Id be happy to miss them if they came up. It really took the pressure off. There is way more important stuff to study besides this, so if you only have limited brain capacity like me dont stress about it. Behavioral: I watched the Kaplan videos for this. BIG waste of time. This guy seriously thinks hes a fucking rockstar and will try and sex you through the camera lens. Just review whats in FA and make sure you know and understand your statistics. There were a few questions on Sn, Sp, PPV, NPV and also the various types of experimental models (cohort, cross section, etc). These can be pretty easy points, so do some practice questions with calculations til you are proficient. If you are a little weak here, I would recommend the Kaplan videos just for the stats sections, but not really anything else in behavioral (unless you really want some comedic relief). Uworld will fill the gaps in FA as this topic is mostly a bunch of touchy-feely crap thats hard to study for. Genetics: FA is sufficient if you already understand how to calculate probabilities and how to determine whether disorders are recessive, dominant, or sex-linked based on the family tree. I dont recommend memorizing what the trees look like because itll be easy to get mixed up when you are rushed. If you are a little weak on this, spend a day watching the Kaplan genetics videos. The guy does a pretty good job helping you understand the calculations, but ultimately the information in FA is sufficient once you understand all of it.

Basic Path and Other Crap (cellular injury, inflammation, neoplasia etc): FA is piss poor. There are 11 hours of Goljan on this basic stuff, listen to it and read along with the transcripts. The Goljan Rapid Review text has excellent chapters on this if you are having trouble understanding. Immunology: For this I would highly recommend the Kaplan videos as well as the few hours Goljan spends talking about inflammation. Fill in gaps with the Rapid Review textbook if you are confused, especially about interleukins and inflammation. Annotate your FA as you go along, but dont bother adding in diseases that are not listed in FA (this is a general rule as well if the disease is not mentioned in FA dont bother with it). The immunology questions on Step 1 really require you to understand the mechanisms of how shit gets activated and works together as well as the various diseases caused by deficiencies. FA has a page with a good list of the immune deficiency syndromes, know them well and how the patients would present. Biochemistry: I forgot ALL of biochem by the time 2 year ended, so I was a bit worried at first. But the Kaplan videos are excellent and explain everything very well. Keep in mind that most of what you will be asked on step one in regards to biochem has to do with disease processes, not rd what is the 3 enzyme in the TCA cycle. The questions will require you to know the cycles and enzymes, but more importantly know their clinical significance when something is missing or goes wrong. Know how the patients would present. Ultimately, FA has all of this covered very well. If you feel good about biochem and still remember it and dont need to relearn it from scratch, FA would be more than sufficient at covering all the important topics and you can skip the Kaplan vids. Use Uworld to gauge your proficiency. Most of the biochem questions are very easy and straightforward and I had very few on my exam, although Ive heard differently from others. You DO NOT need to go read a biochem textbook, that would be an incredible waste of time. Microbiology and antimicrobials: Probably was my weakest and least favorite subject. I began by try to read through microbiology made ridiculously simple (MMRS) because everyone kept saying how awesome it was. Its a great book for learning micro during the year, but its overkill for boards. 300+ pages is way too much information for one subject and I dont think theres any way to read through and memorize all of that in just a few days. FA has all the bugs and drugs you need to know, but its kind of hard to go relearning it that way when youve forgotten all of it (or never learned it properly in the first place). So I actually grabbed the Kaplan textbook from one of my friends because it was much shorter and covered all the high points of each bug. The Kaplan videos are good for explaining the antimicrobials, which are a huge pain in the ass in my opinion. Good thing was that I dont recall any questions requiring you to know the spectrums of each drug, but you will need to know their mechanisms AND how bugs defeat the antibiotics AND even how different bugs freaking acquire their antibiotic resistance genes, which includes some crazy kinky bacterial shit. Ultimately its just rote memorization here, sorry. Also, I realized that I spent so much time memorizing little details about each bug that I really had no idea how the patients would present. Basically, while it is important to know how tularemia is transmitted, it is MORE important to know what the hell a tularemia patient looks like. Micro is also the only section where I think its important to know the MCC in terms of pneumonias, meningitis, etc. in the various age groups and immunocompromised states. Viruses, bacteria, and fungi are all important. Helminths are not. Fuck em. Pharmacology: Get the BRS pharm flashcards (they also have an iPhone app), these are very good for review of common side effects and mechanisms. If the drug is not in First Aid, dont bother learning it even if it shows up in Uworld. The test focuses a lot on knowing the class of a drug and its side effects, and FA has them listed out and organized quite well. If you are having trouble though with practice questions or understanding mechanisms, the Kaplan pharm videos are EXCELLENT. They may help you understand the material, but there wont really be any direct
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questions requiring you to know the additional information that you get from these videos. If you feel comfortable and like the FA layout and are getting your Uworld questions right, you can safely skip the Kaplan videos. I covered pharmacology along with each organ system. The exception is autonomic pharm, which has its own section in FA. I would watch the Kaplan video for this section because it will ensure you understand the mechanisms of each of the autonomic drugs, which is very, very important. They can ask questions on these any which way, and youll only be able to get them right if you understand what receptor the drugs are acting on and what the downstream effects will be as well as reflex responses. Memorizing will get you nowhere here. Again just like biochem, dont be a hero and try and read a textbook. I will be in the library this summer pointing and laughing at anyone with pharm or biochem textbooks. Seriously. Physiology: There are very few questions, if any, which ask basic physiology. All the physiology you need to know is integrated with the pathophys. For example, you need to understand how lung elasticity works, but only in the context of a disease processes like emphysema and fibrosis. For this reason, I dont recommend reading through BRS and trying to learn all of physio. FA covers enough of the physio you need with the organ systems, but make sure you UNDERSTAND it. If you get to the section with cardiac output and dont really understand whats going on, go back to BRS physio and read up on it. Otherwise, dont bother learning the extraneous information in there thats not in FA and doesnt show up in practice questions. Im sure you guys are getting the picture now that most of the book recommendations that people make for each subject are NOT necessary to actually read. Just use them as a reference if theres something you dont get and that a Uworld explanation doesnt explain clearly enough (which is rare). You do NOT need to sit and read ANY full text for ANY subject, got it?? Pathophysiology and Organ Systems: Goljan audio, Goljan Rapid Review textbook, and UWorld. When you start an organ system, go ahead and cover the embryo and anatomy. Then listen to Goljans audio files with the transcripts in front of you. Once you get through that, flip through FA and see if there are diseases in there that you dont quite understand or never really got in the first place. For these, go to the rapid review textbook and read up on them, annotating your FA wherever you need. There is no need to actually sit and read through all of Goljan Rapid Review. Use it as a source to fill in gaps. It does have more information than you really need. The remaining gaps in your knowledge will be filled when you do questions. Always annotate FA with extra info gleaned from Uworld, especially if it shows up repeatedly. Like I mentioned, I did about half my questions for the day on the topic I studied, and the other half cumulative of what I had learned so far. I think its ok to include questions on topics you have not yet covered IF you feel somewhat comfortable with them and can at least make educated guesses towards the answers. But if you find yourself getting a lot of questions in a certain area where you have no clue, go ahead and leave those questions out until you review the material. Otherwise, you will just be wasting good questions and trying to learn little bits of information about various diseases without having the big picture. A good general rule when learning about the ins and outs of diseases, make sure you know how the patients would present to you. The questions on step one will never be what is associated with such-and-such disease. Its always patient presents to you with these symptoms - what is the test to order, or what else is associated with this condition, or how would you treat this patient. In essence, its multistep reasoning and you have to be able to identify the disease and THEN answer a question about it. If you miss out on the first part you can bend over and kiss your ass goodbye. This is why I keep beating into the ground that it is so important to understand WHY things happen and HOW things work. They will present the problem to you in ways you have never seen and you need to be able to understand whats going on behind the scenes to answer the question. Theres no way to do this if all youve done is memorize.

Molecular Biology: This doesnt even deserve an italicized heading. Some genius last year said to read HY molecular biology because it could help you get a few off the wall questions right. And then there was a huge ordeal about what edition of the book was best, and how the older version for more concise and a better read. Whatafuckingjoke. First of all, there were maybe 3 questions like this on my entire test. Second of all, these so called off the wall molecular bio questions were actually problem solving questions that tested your critical thinking ability and required no actual knowledge about the shit involved. They contain markers, enzymes, or tests that youve never heard of (probably not even if you had read that damned book), so youre sitting there thinking HoOOoOooly crap wtf is this??!1! Heres a tip: if you get to a question that you have no clue about and is full of crap youve never heard of or cant pronounce, its probably one of these questions. Pick an answer and skip it (no penalty for guessing). If you have time at the end of the block, go back and think your way through the question. Start eliminating answer choices and in the end there will only be only logical one left. Practice Exams You will inevitably read all this crap about what practice exam is best and most predictive of your score and blah blah blah. Its all horseshit. Everyones Step 1 is different and just because some moron on studentdoctor had a board exam similar to one of the NBMEs he took, it all of a sudden becomes the most representative. News flash: theres no way to control what you will get on your test, so dont worry about what practice exam you take. I chose NBME 5 and 6 because they were the most recent, and did them approximately 1 week and 2 weeks out from test day. And just to prove my point, all the crap on the interwebs said that NBME 5 and 6 over predict your score. Mine went UP by 10. So there you go. Anyways, like I said earlier, NBMEs are the best way to predict where you are score-wise and where your weaknesses are. There are no answers provided at the end, but I did sit and compare with friends on a few sections to review. Also, there are bootleg versions out there with bootleg answer banks and bootleg score converters. Dont use that shit. The answer banks are what some random dude out there thinks the answers are and they are blatantly wrong in some cases. Also I dont know what Einstein developed the score converter, but it doesnt fucking work. So suck it up and fork over the money to buy the exams, they are well worth it. I think you can generally expect to be within +/- 5 points of your NBME score. Dont get too caught up in trying to get a score prediction within a point or two, there are just too many variables on test day and nobody really knows how the damn thing is graded. On a side note, my theory is that if you get more difficult questions right (i.e. questions that more people have missed), it will boost your score more than getting an easier question right. So if you can nail a couple of those difficult molecular bio ones I mentioned earlier, it should help quite a bit. Test Day You are finally here after 6 weeks (and yes it had better be 6 weeks) of studying your ass off nonstop and hardly seeing the light of day. Now its time to relax and breathe. Take the test as if it doesnt matter, stress will only hurt you. Also, go with your first gut reaction on each question. If you are reading the question and an idea pops into your head and you see it in the answer choices, 99% of the time you will be correct. They are NOT trying to trick you on this exam, if something seems correct it probably is. If you go back and rethink your answers you will inevitably fall into a pattern of circular logic and end up confusing yourself. Go with your gut, move forward, and dont look back. The only time you should go back to a question is if you didnt have enough time to think it through on the first go-around. Otherwise, if you picked what you thought was the best answer, do not second guess and just leave it be. This is crucial to good test-taking.

I believe you are given one hour of break time to split up however you like. You should do the training/orientation the day before the exam by going to the NBME website and downloading their test application. This will give you a feel for where everything is and how its set up, and will also save you 10 minutes on test day, which can be added to your break time. If you finish a section early, you can sit there and relax without leaving the section. If you end a section early, you do not get extra break time added. For example if you finish with 5 minutes left, and you quit the section, those extra 5 minutes do not get added to your break time. I powered through the first two sections with no break, and then took 5 minutes after block 3, 20 minutes for lunch after block 4, and something like 7-10 minutes between the remaining sections. During your breaks, drink water, go pee pee, eat a little snack, go outside and get fresh air. Do not ponder over your answers or try and study. And when you are finally done, go enjoy your 2 weeks off and forget about all the stresses of med school. Grades come in about 6 weeks if I remember correctly. My Scores I only include these to validate that my crazy strategy can actually work. NBME 5 (two weeks out): 238 NBME 6 (one week out): 253 Step One: 263/99 Sincerely, rd Your friendly neighborhood 3 year If you have questions, feel free to email me: step1sucksass@gmail.com