How I made it through USMLE Step 1

As a medical student from Czech Republic I have once decided to do USMLE and get a residency spot in the United States. This is the first part of the story.

Disclaimer: My final score (244, August 2015) is not high nor too low. Please consider this while taking any advice.

Light of computer screen is shining in my face. I’m sitting in a tiny chilly room somewhere in Croatia, 500 km from home for almost seven hours straight and reading like a three hundredth clinical vignette in a row. I feel tired, hungry, frustrated, upset, angry and in peace at the same time. “I don’t know if after finding out that my hypothetical colleague is probably drunk at work but doing no mistakes should I report him to my supervisor, hospital committee, national committee or some other committee that I absolutely don’t recognize,” I thought to myself and checked some answer. “Two years of preparation and I get this type of questions that no book prepared me for. Let’s just quickly get over it.” I started to think to myself if this wasn’t just a big waste of time, money and well, life energy. It’s late August and all of my friends are enjoying summer from the start. I, on the other hand, have spent almost all of the free time studying indoors.

Don’t get me wrong, it wasn’t all that bad. There are many bright sides of USMLE and you will see them more clearly later (partially because of repression of bad memories). But as I see it so far? It’s like a mysterious love-hate relationship: you will love it and you will hate it. It will affect all parts of your life and all of your closest friends. Your social life will suffer. But in the end, for me it’s been one of the best decisions of my life.

Prologue

Let’s rewind time a bit. It has all started 2 years ago by the end of the summer of 2013. I finished my second year and was enjoying some precious free time. And by free time I mean looking for a new thick books for upcoming subjects and exams with a two-column format and small font-size that I loved back then.

Then I accidentally bumped into a term ‘USMLE’ and some big coincidences happened consequently. In a period of few days/weeks I randomly ran into slideshow presentation about USMLE on website of my faculty, Czech experience with US residency, Step 1 report from my colleague Marek Čierny, local study group and finally scholarship had been established for successful examinees.

“And, when you want something, all the universe conspires in helping you to achieve it.” — Pablo Coelho

All these events felt like more then just a independent coincidences. From there the forces were set in motion. I was gradually looking for more and more information about the examination itself, all the Steps, electives, residencies, literature and so on. It didn’t take long to my final decision: to do all of this and get a job in US.

I had to fit all this in my medical curriculum so I asked a lot of people about their own experiences and what do they recommend. Originally I planned the Step 1 for the fourth year and finally set the eligibility period for the summer before the beginning of the fifth year. I didn’t plan much in front because too detailed plans are more likely to fail somewhere in the future. For me, ‘to react’ is much better attitude than ‘to calculate every single step precisely’.

“By failing to prepare, you are preparing to fail. “ — Benjamin Franklin

I have to say, I’d always been inconsistent about the final destination of this journey. There was time when I absolutely wanted to go to US and start a new life there. However there also was a time when I just wanted to do USMLE just for the sake of experience and knowledge. But I’d always had in my mind that if I won’t start early, someday it might be too late. For anything.

What I did & would’ve had done again

Although I strictly avoid to give any kind of exact or tailored advice, here’s a list of few things/habits that I did and actually found kind of useful later:

Picked USMLE-oriented book for every subject

As advised from Marek, I picked one book for every subject. I don’t like to read long bland texts, so I’d always tried to choose a well structured, shorter, more dense but comprehensive one. Preferably written in lists rather than paragraphs. First it takes tremendous time to read it all, but later it saves precious time during reviewing.

Studied from USMLE book for oral exams

From my experience at Masaryk University most of the Czech textbooks are unorganized, redundant, too detailed and one more time, redundant. It almost looks like author writes a novel, not a textbook. USMLE-oriented books are focused on high-yield, most important and common tested (i.e. generally important) knowledge.

“I’ve never let my school interfere with my education.” — Mark Twain

With this approach I was able to build a solid foundation for every subject. And in my opinion, general picture and strong fundamentals will always be superior to random in-depth details, not just for the purposes of oral exams but for general practice as well.

Focused on mechanisms (why & how)

As Dr. Goljan always emphasize in his audio lectures: focus on why. The mechanisms. Why and how does it happen. If you can understand well how does it happen then you have no problem to figure out most of the typical clinical presentations that they always ask about. It’s easier and in long term more sustainable than memorizing the lists.

Stuck with the ‘First Things First’ principle

The most important things come first. I realized that if there is only one thing I would have to remember from various topics, it would be always the most common … (cause, presentation, mechanism, drug, adverse effect,…). I’d always approached this first, only then went for more details. Fundamentals over details, remember?

Learned the differences, not similarities

I’d tried not get lost in similarities and focused on, as Dr. Conrad Fischer says, “What is different? What’s unique?”. For example in orotic aciduria, a disease with deficiency of UMP synthase (pyrimidine synthesis pathway enzyme), and OTC deficiency, a defect in enzyme of urea cycle, would be increase in orotic acid in urine in both of the cases. But only in latter there would be hyperammonemia, the distinguishable feature, because of disrupted urea cycle.

Thoroughly reviewed ‘the big four’

The big four for me is pathology, pharmacology, microbiology and physiology. The subjects that most of the USMLE questions are all about. In my opinion, if you do well in these, you will succeed. I went through Goljan’s RR and Pathoma so many times you would have to take your socks off to count.

Made time to motivate and inspire myself

Every now and then I had a crisis. I felt like it’s just too much, it’s not worth it and even if I would make it there is a war to win, not just a battle. This could create a vicious circle of self-doubt and procrastination. As I learnt from Ido Portal, it’s important to actively make an appointment with yourself and think about why you do it and what do you gain in the end. And when the time of crises came, I reminded myself what motivates me and drives me forward.

Had a day off regularly

In a more advanced and intensive phase of the studies I tend to forget to take a break. I experienced this many time during regular school exams and I paid the price every time. This time I did it differently. I studied 6 days a week and set a regular day off. I tried to actively plan something (a trip, work out, movies, …), so I’d always had something to look forward to.

“Don’t do the work if you don’t have the balls to rest.” — Gym Jones’ T-Shirt

Canoe trip with my girlfriend on our day off

What would I have had done differently

As time went by and the test date was inevitably getting closer, I started to realize where I made a mistake and what I had to the better next time for the Clinical Knowledge.

Done as many questions as possible, as early as possible

Here’s the truth: Step 1 is a test. Shocking right?! Even though it correlates significantly with your true general knowledge of tested subjects, it is and always will be only a test. And like all tests there are some rules and limitations. At some point, the best preparation for, for example push ups, is doing push ups. So, in my opinion, to excel in Step 1, do the questions. As many as possible. At the beginning even few questions a day are better than none.

Studied in more depth question by question

It is well known that USMLE-style clinical vignettes are multi-step questions. They will present you, for example, a typical case of meningitis and ask you a question about details of immune response to vaccination for meningococcus. So what should I have had done is, when encountered with this type of question (or any other) I should’ve had studied all about about meningitis, differential diagnosis, pathophysiology, immune response, endotoxin, treatment, pharmacology, adverse effects and common vaccines. And then put it together.

The main reason I wasn’t doing that was its tremendous time consumption. I approached differently, system by system. But now I think that the former approach is better and longer-lasting. It is more exhausting at first, but later it’s easier and more satisfying to actually know all about the particular clinical problem.

Done more diagnostic tests and more simulations

To know your weaknesses is a huge advantage in a battle like this. Early self-diagnosis and simulations are worth the extra money. In a Step 2 CK preparation, I will do diagnostic test as early as possible (think first of course, if you don’t know a thing, save the money). This will allow me to focus on my weaknesses. As the real test comes closer, regular simulations help with predicting outcome and to simulate real-life experience (seven or eight hour test is not something you do every day).

Not ignored behavioral sciences and ethics

I knew this is my weakest link but always reassured myself that there won’t be too many questions. I was wrong. These were easy, basically give away questions that I wasn’t able to answer correctly. I ignored relatively easy topics in order to review more important ones one more time. It could be another 5 or 8 points for me. Yeah, just like that.

Recommended literature & study materials

Since the beginning I’d tried to read as much English literature as possible. Here is a list of few books and materials I studied from and definitely do recommend to everyone. All of them are a ‘must have’, except of Pathoma: it’s an absolute ‘must have’.

Pathoma — Fundamentals of Pathology

An absolutely flawless masterpiece. This is the best textbook (medical course review) I’ve ever experienced. Dr. Sattar in his video lectures explains everything in a simple, comprehensible way. His passion for pathology and education can be felt in every lecture. Even in the fifth year I miss watching his lecture and I would like to experience it for the first time one more time. This is absolutely a ‘must have’!

Goljan’s Rapid Review of Pathology

This is another pathology textbook written in a modern, listed way. But don’t get confused by the title. It’s a big book and more detailed than Pathoma. I went through it multiple times as it’s a valuable source of knowledge. As I said earlier, Dr. Goljan focuses on mechanisms and pathophysiology of diseases, rather then just a list of symptoms. Conclusion: Great source, but do Pathoma first.

Kaplan’s Pharmacology Video Lectures & Lecture Notes

Many people struggle with pharmacology. They get lost in list of drugs, adverse effects and clinical applications. Dr. Raymon with his sense of humor, emphasis on mechanisms and little differences in drugs of the same class will get you to love pharmacology. With this video series, I’d always looked forward to another chapter.

First Aid for the USMLE Step 1

The perfect companion for USMLE review. Almost everything you will encounter on the test is written here (somewhere).

BRS Physiology

Great and comprehensible review of physiology. I actually recommend this book for my colleagues preparing for physiology oral exam.

Clinical Microbiology Made Ridiculously Simple

This is one of the first books I encountered during my studies for USMLE. It’s very easy and actually fun to read. Lot’s of mnemonics will help you to get through all the microbes easily.

Epilogue

After finishing Step 1 test: toast to a better future

For a while there was a relief. Four weeks later I got the results. And the rush started again.

Now the plan is to do Step 2 CK by the end of 2016. In the summer of graduation year of 2017 to do the clinical electives (possibly Mayo Clinic) and Step 2 CS. After that … it depends. I’ll keep you updated.

“Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.” — Winston Churchill

One Comment

Mohid June 25, 2020 Reply

Dear Dr. Vataha,

Firstly, I commend and congratulate you on your journey to ECFMG registration. Could you please make a separate blog discussing your experience when submitting your residency application and the match cycle.

Many thanks.

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