There are two things you can always count on in medical school: endless studying and exams. The USMLE Step 1, in particular, is one of the most stressful and difficult exams you will take in your medical school career. Your performance on this exam will essentially set the tone for your success, or failure, in the residency match process.
Make no mistake, competitive residency programs place significant emphasis on your USMLE Step 1 score because, in most cases, it is the only standardized and objective evaluation of your scholastic performance.
Basically, you must do well on this exam. Not only does it show your discipline and ability to study and synthesize an astronomical amount of information, but it also demonstrates your ability to perform when it really counts.
When I took the Step 1 in 2009, I used all the major prep methods, including First Aid, USMLE World, BRS, and Kaplan. Despite feeling well-prepared on test day, there were a few aspects of the exam that caught me by surprise. I have compiled a list of these key pearls below, in hopes that they will thoroughly prepare you for the most important exam of your life!
1. Long question stems
One of the most surprising aspects of the Step 1 was the sheer length of most questions. Although I thoroughly studied for months in advance of the exam, I was pretty shocked. I practiced many sample questions, but the sheer length of the Step 1 questions was unparalleled. Here is a sample question to illustrate the typical length:
A 45 year-old man with no significant past medical history presents to the emergency department with thunderclap headache. Three hours prior to presentation, the patient was in his usual state of health and at home drinking alcoholic beverages with several work colleagues when he complained of the “worst headache of his life”. He consumed aspirin and acetaminophen to relieve his headache, but was transported to the hospital by ambulance once the pain did not abate. On examination, his vital signs are: temperature: 37.5oC, Pulse: 75 bpm, BP: 145/90 mm Hg, Respirations: 10/minute, Pain: 10/10. He is alert and oriented to person, place, and year. Heart and breath sounds are normal. Neurologic exam is significant for photophobia, neck stiffness, and severe headache. Motor strength and sensation are intact. Family history is significant for diabetes and hypertension in the father and renal tubular acidosis in the mother. Social history is significant for occasional cocaine abuse, last time was earlier today. The patient works as a lawyer. He takes a daily multivitamin, but no other medications. A non-contrast computerized tomography scan of the head does not show evidence of hemorrhage. Urine toxicology is positive for marijuana and cocaine.
Labs: Na: 141, K: 4.1, Cl: 120, CO2: 21, BUN: 20, Creatinine: 1.1
CBC: Hb: 12.0, Hct: 40, WBC: 13K, Plt: 350K
Coags: PT: 15, PTT: 35, INR: 1.0
A lumbar puncture is performed to confirm a tentative diagnosis of aneurysmal sub-arachnoid hemorrhage.
OP: 30 cm H2O, WBC: 5, RBC: 30K, glucose: 100, protein: 120, gram stain: no organisms. CSF color: xanthochromic.
The patient is transported to the angio suite and undergoes a digital-subtraction angiogram. He is diagnosed with a ruptured posterior communicating aneurysm and is promptly transported to the operating room for microsurgical clip occlusion.
Which of the following is the greatest risk factor for aneurysm re-rupture in the next 24 hours?
Most questions on the actual exam are similar in detail and length as the sample above. Multiply this by 50 questions/section with multiple sections and you are asking for a ton of reading. It’s exhausting! As you can see, the body of the question stems are loaded with extraneous information placed there to steer you in the wrong direction. For better or for worse, expect to be provided a full set of vitals, labs, and detailed physical exam for most diagnostic or clinical question.
A key test taking strategy is to skip to the bottom of the question stem and read what the test writers actually want you to answer. Once you know where the question is heading, you can re-read the question stem. In this case, you probably do not even need to read the stem in order to come up with an answer.
Test Advice: Skip to the bottom of the question stem and read the actual question itself. In many cases the question text is not helpful and will only consume time.
2. Numerous Answer Choices
The boards will often provide tons of answer choices that make the process of elimination very difficult. For example, here is the same question above with a list of possible answers:
A 45-year-old man with no significant past medical history presents to the emergency department with thunderclap headache. Three hours prior to presentation, the patient was in his usual state of health and at home drinking alcoholic beverages with several work colleagues when he complained of the “worst headache of his life”. He consumed aspirin and acetaminophen to relieve his headache, but was transported to the hospital by ambulance once the pain did not abate. On examination his vital signs are: temperature: 37.5oC, Pulse: 75 bpm, BP: 145/90 mm Hg, Respirations: 10/minute, Pain: 10/10. He is alert and oriented to person, place, and year. Heart and breath sounds are normal. Neurologic exam is significant for photophobia, neck stiffness, and severe headache. Motor strength and sensation are intact. Family history is significant for diabetes and hypertension in the father and renal tubular acidosis in the mother. Social history is significant for occasional cocaine abuse, last time was earlier today. The patient works as a lawyer. He takes a daily multivitamin, but no other medications. A non-contrast computerized tomography scan of the head does not show evidence of hemorrhage. Urine toxicology is positive for marijuana and cocaine.
Labs: Na: 141, K: 4.1, Cl: 120, CO2: 21, BUN: 20, Creatinine: 1.1
CBC: Hb: 12.0, Hct: 40, WBC: 13K, Plt: 350K
Coags: PT: 15, PTT: 35, INR: 1.0
A lumbar puncture is performed to confirm a tentative diagnosis of aneurysmal sub-arachnoid hemorrhage.
OP: 30 cm H2O, WBC: 5, RBC: 30K, glucose: 100, protein: 120, gram stain: no organisms. CSF color: xanthochromic.
The patient is transported to the angio suite and undergoes a digital-subtraction angiogram. He is diagnosed with a ruptured posterior communicating aneurysm and is promptly transported to the operating room for microsurgical clip occlusion.
As you can see, there are a lot of choices. The test takers do this purposely to throw off your ability to narrow down to the correct answer. Not only do you have a long question stem, but a similarly long list of answers.
Test advice: The best strategy here is to try your best to eliminate answer choices to the best of your ability and go with your “gut” feeling. The only way you will feel comfortable taking the boards is to take many practice tests and answer many sample questions.
3. Biostatistics
There has been a growing emphasis on the inclusion of biostatistics on the boards. Unless you are very comfortable with principles such as positive predictive values, Kaplan-Meyer curves, hazard ratios, and number needed to treat, this will be a difficult portion of the exam (like it was for me). You will be expected to rapidly interpret esoteric, complex studies that utilize uncommon statistical methods to present results. I suggest spending a good portion of your studying time to practicing biostatistics questions and getting comfortable with the terminology and calculations. This is key to doing well on the Step 1. Do not underestimate the difficulty and sheer quantity of biostatistics questions that will be asked.
Test Advice: STUDY BIOSTATISTICS
4. Interpreting experimental results
Many of the pharmacology and physiology questions will be presented in the context of a theoretical experiment. The board examiners are not going to ask you something simple like “what enzyme is irreversibly inhibited by aspirin,” but rather, something more like this:
A scientist develops three novel medications (Compound A, B, C) to use as a potential adjunct to aspirin for the treatment of coronary artery disease. The scientist develops a platelet aggregation assay that specifically measures bleeding times.
The test examiners love asking these types of questions because they are complicated and challenge your ability to synthesize and master several concepts at once. In order to answer these questions correctly, you need to understand mechanisms, pathways, and the names of virtually all the anti-platelet and anti-coagulant medications.
Test Advice: Make sure you are comfortable with concepts such as the mechanisms of actions of medications and enzyme receptors. Realize that you will often be asked these questions in the context of an experiment rather than a simple regurgitation of facts.
5. Not many “find the diagnosis”-type questions
At its core, the Step 1 is a basic science examination. Although you will be asked a handful of clinical questions, the bulk of this examination is interpreting experiments, understanding physiology and biochemistry, recognizing histopathological slides, etc. This is not an examination that will ask you many “pick the correct antibiotic(s) for ventilator-acquired pneumonia” or “what is the diagnosis?” type questions. These are questions that are generally reserved for Step 2 and 3. Focus your studying on pathology and pathways rather than the clinical signs and symptoms of bacterial endocarditis. Rather than examining how hypercortisolism causes the classic phenotypic features of Cushing’s Disease, know how cortisol is a steroid hormone that binds to an intracellular receptor (rather than cell membrane receptor).
Test Advice: A common mistake is to spend the bulk of your time studying clinical questions which are generally tested on the Step 2. Focus your practice questions on mechanisms, pathways, experiments, biostatistics, and genetics. These tend to be the most heavily tested subjects.
In conclusion, the Step 1 is hard. The time-tested advice of doing many practice questions, studying early and efficiently, and using high-yield test preparation books will be key to your success. While specific test preparation tips are outside the scope of this article, over the next several weeks, I will provide some additional studying tips and tricks to help guide you. Good luck and study hard!
Dr. Jonathan Rasouli is a sixth-year Neurosurgery resident at the Mount Sinai Hospital in New York, NY. He is a graduate of the Albert Einstein College of Medicine and was elected to Alpha Omega Alpha during his senior year in medical school. His research interests include neurosimulation, translational medicine, healthcare informatics, and deep brain stimulation. He was a 2017–2018 Doximity Fellow.
