Your First Big Hurdle in Medical School

I got a fairly decent but not spectacular score on both Step 1 and Step 2 of the USMLE (United State Medical Licensing Exam) so I am not claiming any revealed wisdom or special insight into the tests. You must take what follows as my opinion alone and I caution you to study for the test in a manner which feels right for you.


For the uninitiated, the USMLE is a three part test which you will take at various times in your medical education. Step 1 is typically taken at the end of your second year of medical school and covers what you should have learned during that time. Step 2 is typically taken during fourth year and emphasizes the clinical aspect of medicine. Step 2 includes the “Clinical Skills” test which is a day-long standardized patient exercise that will cost you a thousand bucks. The only difference between paying a thousand bucks for the clinical skills test and being mugged is that you can’t file a police report after the test. (But more on that in a future post.)

Step 3 is usually taken early in your second year of residency and is your last hurdle to becoming a licensed physician.

Let’s talk about Step 1. Although you have spent the previous two years in the intense study of medical knowledge you will have to study for this test. I am sure that the average medical student can take the exam “cold” and probably pass it three times out of four with a grade close to the minimum passing score. A pass is a pass of course but a low Step 1 score will adversely impact your ability to match into a competitive specialty or a generally non-competitive specialty at a competitive program. In fact, many residency programs screen applicants by Step 1 scores so a low score will automatically close many doors for you.

Additionally, at all American medical schools Step 1 is a “must pass” test and you cannot advance through third and fourth year until you do so. At most schools you will get three chances to pass it. Upon failing the first time you will probably be pulled out of the third year rotation schedule and during the block you sit out you will be expected to study for and pass the test (this time comes out of your vacation). If you fail it for a second time you will be dropped back a year. Fail it a third time and they stick the fork in you as you are done.

At most schools you must attempt Step 2 before graduation but passing or even having the scores back is not required to graduate.

The question then becomes how long and what should study?

The answer depends on your school. My medical school had an eight-week break between the end of second year and the first day of third year. Most of my classmates elected to take Step 1 during this time either earlier or later depending on their comfort level and study habits. I believe that eight week is too long as you will invariably both lose your edge and also start to forget what you studied ealier. Three weeks is not enough time as you do have a lot of information to cover. Five to six weeks seemed to be the average in my class.

If your school doesn’t give you this kind of time then you need to make the best of it.

To study effectively you need to understand the format of the test. Step 1 and Step 2 are day long, computer-based, multiple choice tests. They are broken into hour long blocks of fifty questions selected more or less randomly from various subject areas of medicine. No two tests are exactly alike but an effort is made to keep the relative level of difficulty and mix of subjects more-or-less constant.

The tests are multiple choice but are not like the multiple choice tests which are probably the norm at your medical school. First of all, many of the questions have choices “a” through “k” rather then the standard “a,b,c,d.” You are consequently going to work a lot harder at eliminating wrong answers.

Additionally, the tests are concept-based, not fact-based, and feature many of what I like to call “double pump” questions. Rather than presenting you with a set of information and asking you to name the disease, for example, the typical Step question presents you with a brief case summary after which rather than asking you to name the disease the question might be, “What is the next step in the management of this patient?” Your excitement over knowing the disease was premature as this is not the answer they are looking for.

Heck, in many questions they tell you what is wrong with the patient. Consequently it pays to read the question at the end of a long paragraph first as the presentation is irrelevant once you know the diagnosis.

Another popular question style is to present you with a case followed by a selection of different lab results, your task being to pick the one which fits the presentation. You can usually eliminate most of the possible answers as obviously wrong (high pH in a set of lab values that you know should describe acidosis, for example) but invariably you will be left with a handful of reasonable looking results.

A variation on this is to present you with various simplified graphs and ask you to select the one which correctly represents the case.

Then there are the deceptively simple Behavioral Science questions which present you with a scenario and give you a list of choices only a few of which you can obviously rule out. The rule of thumb here is when in doubt go with the politically correct answer. Spanking is always wrong and it is never correct to advise a patient take responsibility for their actions.

I would say that of all the questions on Step 1 and Step 2, only a handful had a discrete, definite answer like “Sickle Cell” or “Guillan Barre Syndrome.”

So how should you study?

First, do not attempt to go back and review two years worth of class notes. The typical lecture curriculum probably has close to 4000 lectures in two years and you simply do not have the time. Not to mention that since the Step tests are standardized and your curriculum is not (despite the best efforts of your faculty) you might waste your time studying something taught at your school which is not emphasized at another and not likely to be included on the test.

Second, do not read text books because if your lecture notes are full of trivia the text is even more so. Again, you do not have time. This also goes for review books and I confess that I had a change of heart on this between Step 1 and Step 2. You simply do not have the time to review two years worth of material. The four weeks or so you will devote to study will dwindle quickly and your studying will bog down in a quagmire of detail.

Frankly, the best way to study for Step 1 is to do well and study hard during first and second year. You will retain more than you imagine and this is the best base for the most effective Step test study method which is to do practice questions and little or nothing else for your alloted preparation time.

The best practice questions, in my opinion, are those sold on-line by Kaplan or USMLEworld qbank. These are subscriptions to about 2000 questions each which are formatted exactly like the real questions, cover the same mix of subjects, and can be taken in Step-like blocks of questions exactly like the real test. The best part about the service is that you can read the explanations to the correct answer as well as to the wrong answers which in my book is just as important.

As I did the questions I made a point of reading or at least skimming all of the explanations to the right and wrong answers on all of the questions about which I had any doubts at all.

The advantage of these (and similar) on-line question banks are many. First, they are the exact same format and feel of the real test and will get you used to the “physics” of the computer test. That way there will be no nasty suprises on test day when you suddenly run out of time on several blocks or wrestle with the interface.

Second the questions focus on subjects which are actually tested. This means that you are going to get the typical standard presentations and basic medical knowledge with nothing coming out of left field. It was my sense that the questions are not written to trick you and it is only your lack of knowledge which can confuse you. The hoofbeats are always horses, never zebras.

Another advantage is that the questions are phrased and presented in a similar manner to the real test with the important distinction that the practice questions from Kaplan and USMLEworld seemed harder than the real questions. In fact, I scored considerably lower on the practice tests than on the real thing. The practice questions distributed by the USMLE are almost exactly like the real questions in difficulty.

Finally, doing practice questions will put you in the test-taking mode. If all you do is read review books you will have a store of rapidly disintegrating facts jumbled in your head. Doing practice questions narrows your focus to answering questions based on patterns which you have seen before.

Each of these services costs about 100 bucks for a one month subscription . A couple or three thousand quesitons should keep you busy for a month.

A word about “First Aid,” a popular USMLE review book which has an almost cult-like following.

Save your money. First Aid is a collection of “buzzwords” and supposedly high yield facts which are touted by some as all you need to study for the Step tests. I understand that in the old days the Step tests were twice as long but had shorter questions with discrete answers. First Aid might have been useful for a test like that but the nature of the test has changed making First Aid less useful.

Like I said, some people swear by it and claim to to make fantastic scores by studying nothing else. I am skeptical. I hit First Aid pretty hard for Step 1 (before I got smart and started doing practice questions) but I could remember only a few questions on the test where I thought First Aid had even remotely helped me.

Just a few random thoughts:

1. Avoid the temptation to cram the night before a Step test. How much are you really going to retain and more importantly, of the two years of knowledge required to take the test, how much of it can you cram into one sleepless night? Relax. I stopped studying a week before I took Step 1 because I literally could not stand doing another question or reading another page of review material. Remember what I said about peaking early. You just have to know when to say “no mas.” Let your conscience be your guide but it is better to go into the test relaxed (but alert and ready) than to panic and lose sleep over it.

2. It will be a long day. Bring a lunch, of course, and wear comfortable clothes. Paradoxically the day will seem to fly by once you get into the test. You are given plenty of break time but most people just plow through most of their breaks to just get the test over with.

3. I thought I had failed Step 1. I mean, looking back it seemed that every question was renal physiology and that there were only a handful of the 350 question on the test of which I was sure of the answer. It seemed that I could get most of the questions down to two or three choices but I was never really sure on most of my answers.

So I dreaded getting my score and anticipated failing even though the first time pass rate for American medical students is something like 93 percent, I am not stupid, and I studied pretty hard. I asked around and this seems to be a common perception after finishing the test. Almost everybody thinks they bomb it but most people don’t. Move on. Enjoy the rest of your vacation. Unfortunately it will take six weeks to get your results so you have a long wait.

4. Step one is divided into seven one hour blocks of fifty questions. I am a very fast reader so my strategy was to read the question, quickly select an answer, and if I wasn’t sure mark it for later and move on. (The software allows you to select questions within the block for review.) I found that I was able to get through the block in about half and hour leaving me with half an hour for review. Typically I had about half of the questions marked and spent the time wrestling with them. There were always a handful of questions for which I didn’t have a clue and these I marked “C” without wasting any more time trying to figure them out.

The key is to have a system that works for you and not to get hung up on one question. If you don’t know the answer mark it for review and move on. Don’t win the skirmish but lose the war.

I repeat: Take my advice as free advice and thus worth what you paid for it. I welcome your comments but please don’t flame me because we disagree. I am perfectly willing to be corrected, proven wrong, or convinced of your point of view.

3 thoughts on “USMLE

  1. Just wanted to say thanks for your words re: Step I. It’s nice to read that fears of failure post-test are common. I know what you mean about heavy renal phys., and feeling like you only knew a handful of questions “for sure.”

  2. What do you suggest using as a reference if you do not like first aid? I also have very poor notes from my classes and do not have contact with anyone that has good notes.

  3. Panda MD, I would love to know what you think about medical schools in the Caribbean, chances of getting back in, and getting accepted to a residency. Also, what would you choose, DO school or MD school in the Caribbean? Thank you =)

    Ps. I posted this as a comment because I couldn’t figure out how to send you a message/question.

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