Guide to usmle step 1

The Jefferson Medical College AOA Guide to USMLE Step 1

Jefferson Medical College Alpha Omega Alpha
Guide to USMLE Step 1

Introduction

OK, so you're approaching the end of your second year at Jefferson, maybe the most grueling part of your medical education. Having gone through about a thousand pages of Path, and countless lectures of ICM, you are so ready for a major break from the books, right? Well there's still one hurdle to cross before you reach the promised land of clinical medicine: Step I of the USMLE, or "the boards." Although this examination can seem pretty intimidating, a logical and well thought out approach to studying helps the great majority of students here at Jefferson to pass on their first try. So first and foremost, don't panic!

This guide is meant to provide a framework and some simple suggestions for studying for Step 1. Remember, these are just suggestions and no one approach to studying is right for everyone. The key to success is to think about the topics and issues that need to be covered, make a realistic study plan, and then do your best.
To organize this guide, we've separated it into 3 major sections. The first answers some commonly asked questions about the boards. The second section deals with scheduling your study time wisely and efficiently. Finally, the third section discusses the review books that are available within each major subject. Take a deep breath, and let's get started.

Commonly asked questions about Step 1

How important is the score anyway?

For better or for worse, residency programs do look at your USMLE scores as part of their evaluation of resident candidates. It is however just one aspect of your application, which will also include your clinical evaluations, letters of recommendation, basic science grades, and Dean's Letter. The more competitive the specialty (i.e., Neurosurgery, ENT, and Radiology), the more likely the scores will be used to screen students for interviews. If you are leaning towards a particular field(s), ask residents or attendings about the relative importance of Step 1. Overall, just keep in mind that while your score does matter, it is only one of many criteria that will help determine your success in matching at the residency of your choice, so keep things in perspective.

When should I start studying?

The truth is that you started studying for Step I the first day of medical school, since this exam is basically a cumulative exam of the first two years. In terms of focused studying for the boards, however, most students find that 3-4 weeks is sufficient.

Review Courses

Keep in mind that there are also many review courses (Kaplan, Princeton Review, etc.) that can help you organize your studying if you are willing to spend the time and money. If you feel you may benefit from a review course, the best thing to do is to ask someone who has taken these courses to see what they are really about. Kaplan offers a range of products that can help one prepare for the boards. These include Q-Bank ( 2000 test questions that simulate the boards format- a web based product), Intense Prep (live lecture review done in three weeks which also includes over 1000 exam like questions), MedPass (video set lecture series that also includes over 1000 board questions), and other web based products (WebPrep, Qreview). The strength of the Kaplan assets are the simulated tests, which have very similar questions to the boards and have a format that is similar to the boards. Many students find the Q-Bank questions to be particularly useful, as they provide the opportunity to simulate the setting that will be encountered on test day with a computer-based exam. Kaplan also offers a series of review books are part of the above packages. Ask other students who used them if they found them to be effective. The www.kaplan.com site offers more specific details about any of their products.

What topics are more/less emphasized on the boards?

This question is so important, as it will determine how much time you should spend reviewing each subject. Generally, among first year classes, the most heavily emphasized is Physiology. There are also a fair number of questions in Neuroanatomy/Neurophysiology, Biochemistry and Behavioral Sciences, so spend a decent amount of time on these subjects as well (see scheduling section below for more detail). Anatomy, Histology, and Embryology are considerably less emphasized in Step 1, so spend less time studying them but please, please, please do yourself a favor and do not ignore any subject altogether.

As for second year courses, spend the most time with Pathology, Microbiology, and Pharmacology. Pathology is probably the most important single subject, since it ties in all of the other topics; don’t be daunted, though, because the preparation you have received in going through ICM and Pathology in the second year has provided you with a strong foundation when it comes time for Step 1 prep. By devoting the appropriate time and energy and utilizing the right resources, conquering all of these subjects will be well within your reach. Also, don't forget the basics of Biostatistics, as sensitivity and specificity and positive and negative predictive values are favorites for the USMLE. Just knowing these will be worth several extra questions answered correctly.

How important are sample questions and practice exams?

Generally speaking, doing practice questions and exams is definitely helpful for many reasons: it directs your emphasis towards certain topics, identifies your strengths and weaknesses, and gets you in the right frame-of-mind for taking this exam. Many people have found it helpful to do 25-50 questions each night to review the subjects they studied earlier in the day. As the test day approaches, it is probably a good idea to take some longer test blocks back to back to build up your mental stamina for test day.

Kaplan’s Q-Bank has rapidly become a favorite of students here at Jefferson and all over the country. It is favored for providing a good simulation of a computer based test (CBT) and for having a comprehensive database of questions. Many students have reported that the difficulty of Q-Bank questions actually supercedes that of actual Step 1 questions, so don’t beat yourself up if you’re not doing quite as well as you’d like on the Q-Bank question blocks. With the proper preparation, you’ll find your Q-Bank scores and confidence peaking as you near test day. There are also review books out there with practice exams, but none of them are exactly on par with the actual Step 1. Appleton-Lange tends to be more nitpicky, and NMS and Board Simulator Series are both a little more challenging than the boards. A disc containing a sample test is sent with your confirmation packet, and though reportedly slightly less challenging than the actual Step 1, it is also very useful in preparing you for the computer format.
Regardless of how you approach it, practice questions of the proper caliber will be a big help in your review, especially in regard to timing and mental endurance. Also, if you count yourself among the computer-phobic, it may be wise to get some other computer testing resources just to get used to reading off a screen rather than a book. Other possible question sources include: Full Length Practice test for the USMLE by Stanley Zasler, Underground Step 1 questions, and NBME retired questions (which are generally distributed through the noteservice).

How has computer testing changed the exam?

Many people have wondered about how administering the test on computers at Sylvan Learning Centers has changed the boards experience. Though there was much concern among students about the transition from paper to computer, there have been few complaints about the computer format. In fact, many find it much easier to point and click than to fiddle with finding the answer booklet and filling in the bubble.

For those of you who like to circle every word in the question or cross off every wrong answer choice, you will be given a dry erase board, though you may be surprised at how readily you adjust to life without a pencil. There are also relatively easy mechanisms to review unanswered questions or to mark a question to which you want to return, and you should familiarize yourself with these beforehand by using the CD practice test and tutorial you will get in the mail.
If you have had little experience with computers, it would probably be a good idea to use computer based testing resources in your studying so as to familiarize yourself with the basics of answering questions on the computer. Also, as mentioned already, the CD that comes with your packet mirrors the format of the exam and will help you be more comfortable as you approach the test. For the motivated or concerned among you, it is also possible to schedule a practice exam at the Sylvan Centers.

What is the testing day like?

There is no denying the fact that the testing day is long. Just be sure to remind yourself that it used to be two days!!

There are seven one-hour blocks of 50 questions, and you are allotted eight hours to complete the test.
In addition to the exam blocks, your test experience begins with a 15 minute computer tutorial. However, this is identical to the one on the CD sent in your packet, so it is best to skip it on test day and take the 15 minutes as break time. If you do this, you begin with 1 hour of break time, which you are able to take between sections at any point during the day.
Some people complete a couple of sections at a time and then take a prolonged break, while others choose to take a 5 minute break at the end of each section. You can always access a screen on the computer which tells you your total time remaining both for your current section and for the test day as well as how many sections you have left, so time management is not a major issue as long as you pay attention.

The Right Resources: Review Books & Questions

As you embark on your studies for the USMLE Step 1, choosing the appropriate study materials is crucial to your success. There are tons of review books and sample test question books available for your preparation but money and time are two factors you must consider. Many of these review books cost over $25 and take a significant amount of time to go through. Do not stick to one series of review books because you like the format – in every series, there are good books and bad books, and the best strategy is to use the best books from each series as appropriate.

We have broken this guide into categories: general books, book series, anatomy, behavioral science, biochemistry, physiology, microbiology/immunology, pharmacology, pathology, and practice questions.

*Essential resources.

:::::GENERAL:::::

*First Aid for the USMLE Step 1 by Bhushan. Le, and Arnin

We have listed only one reference in this section because this is the best single comprehensive reference for the boards. The book is separated into three sections: the guide to efficient exam preparation, database of high-yield facts, and database of basic science review books. The book was written by med students and continues to be updated every year by med students. First Aid will answer all your picky questions about the exam (# of questions, time per question, scoring, etc.). The high-yield section is very handy and is a great review of all the topics. Reading this section over for the second or third time days before the exam will definitely score you some points. We recommend you use it as a supplement in your study effort. While no one book works for everybody, this book consistently receives the best reviews from students who have taken the boards. First Aid has no sample questions so other references are needed as well. Strong sections: Micro, Pharm and Behavioral Sciences. The sections pertaining to some of the lower-yield subjects (anatomy/embryo/histo) cover a huge chunk of the important and testable items that may show up on the exam, so it is certainly worth your while to know them well. Many people also add important facts in the margins as they study subjects so that during the final few days First Aid becomes the only thing you need to read. Bottom line: this book should become your best friend for the few weeks leading up to the exam, however it is not recommended as a stand-alone reference.

Step-Up to the USMLE Step 1 by Mehta, Lippincott Williams and Wilkins.
It does the high-yield approach by organ system, rather than the by-discipline approach of First Aid. Great organization, but has too many errors. Good as a supplement if you like the style.
:::::BOOK SERIES:::::
Board Review Series (BRS), Lippincott Williams and Wilkins:

Subjects available are Biochemistry, Pharmacology, Microbiology, Gross, Histology and Cell Biology, Embryology, Neuroanatomy, Behavioral Science, Pathology, and Physiology. All books have a similar outline format, lots of charts, sample USMLE-style questions with annotated answers, and a comprehensive exam. These are not textbooks; they are intended for review.

Appleton-Lange Series:

Included in this series are an excellent review book for microbiology and

immunology (Levinson and Jawetz) and a pharmacology review book that is the companion to your

text (Katzung and Trevor). The formats vary. Both the microbiology and pharmacology books have

excellent cases and sample questions.
NMS, Lippincott Williams and Wilkins:

Same publisher as Board Review Series, but these are textbooks, not board review books. There is much more information and detail, with a "dense" format that makes them rather formidable. The only "must have" in this series is a question book/CD called Review for USMLE Step I, 6th edition.

Ridiculously Simple:

The series has Anatomy, Neuroanatomy, Biochemistry, Pharmacology, Microbiology, and Physiology. Minimalist approach as the name suggests with silly, but helpful, mnemonics. The only must in the series is Clinical Microbiology Made Ridiculously Simple.

Lippincott's Illustrated Reviews:

There are three books in this series, Biochemistry, Pharmacology, and Microbiology. Biochemistry is popular as a textbook; it is well-written and well-illustrated, but long for board review. Pharmacology also is excellent to use as a text, but long for a step 1 review book.

High Yield Series, Williams and Wilkins:

This series includes Gross, Neuroanatomy, Biostatistics, Embryology, Behavioral Science, Immunology, Histology, Biochemistry, Cell and Molecular Biology, and Pathology. The most popular books in the series are High Yield Neuroanatomy, High Yield Embryology, High Yield Gross Anatomy, and High Yield Behavioral Science. These books distill the content to an irreducible minimum. No indices, no questions.

:::::ANATOMY:::::

After spending so much time studying anatomy during first year it is kind of disappointing to find out that anatomy is not really a big topic tested in Step 1. You can use this to your advantage by spending more time on other topics. Stay away from Chung and Moore. First, understand that all of anatomy is 1/7th of boards. At a minimum, you will use the anatomy sections of First Aid for the USMLE Step I. We recommend the following books by subsection of anatomy:

(1) Gross: First Aid alone or in combination with High Yield Gross Anatomy. BRS Gross is much too long for board review.

(2) Cell Biology/Histology: BRS – read the first 4 chapters on cell biology; a book to borrow or share.

(3) Neuroanatomy: First choice is *High Yield Neuroanatomy. You must have a neuroanatomy review book in addition to First Aid. BRS. Neuroanatomy is much too long for board review. We strongly suggest you review your neuroanatomy before Brainard's review session: it is a great session but don't worry if it scares you--it scared all of us. There are a fair amount of neuroanatomy questions.

(4) Embryology: First Aid alone or in combination with High Yield Embryology.

Bottom Line Minimum for Anatomy: Anatomy sections of First Aid for the USMLE Step 1, High Yield Neuroanatomy, first four chapters of BRS Histology and Cell Biology and, for more motivated students, High Yield Gross and High Yield Embryology.

:::::BEHAVIORAL SCIENCE:::::

BRS and High Yield are by the same author. Last chapters in either book have epidemiology and biostatistics that are essential for USMLE. Make sure you have a decent understanding of the main topics in biostats. The High Yield book has its fans, but we prefer BRS. Fadem's other review text BRS Behavioral Science Review is a lot thicker, and gives more information than may be needed for the USMLE, but may give a more complete biostats chapter. KNOW THE FIRST AID CHAPTER COLD.

High-Yield Behavioral Science by Fadem

*BRS Behavioral Science Review by Fadem
:::::BIOCHEMISTRY:::::
Biochemistry is a topic that is easily forgotten by the time boards roll around. Going back over all the major metabolic pathways will take time. Choose between Lippincott's and BRS. Both have too much depth and detail. If you used one of these books during first-year Biochemistry, that’s your ideal choice for board review. If not, then it’s strictly your preference – dense outline of BRS vs. bigger pages and pictures of Lippincott’s. High Yield Biochemistry has a concise, no-fat approach; We recommend it only for those with a very strong background in biochemistry. The NBME (National Board of Medical Examiners) always like to ask something about several of the metabolic pathways, esp. glycolysis, citric acid cycle, oxidative phosphorylation, fatty acid oxidation, glycogenolysis, and gluconeogenesis.

*Biochemistry by BRS, Marks
Lippincott 's Illustrated Reviews: Biochemistry by Champe

:::::PHYSIOLOGY:::::

BRS Physiology is a must read book for the USMLE 1. Costanzo does an excellent job summarizing a topic that is high-yield on the boards. You will do well on this subject if you review physiology with the ICM portion of your second year courses; this is essential for doing well in the courses and on USMLE. If you have a firm understanding of everything in the book you will definitely score solid points on the exam. The book is reader friendly and has great clinical correlations that briefly go over ICM topics. By May, you should have been through a review of

physiology at least once. Know this book COLD!

*Physiology by BRS, Costanzo

:::::MICROBIOLOGY/IMMUNOLOGY:::::

These two topics are well liked by the NBME so it is to your advantage to have a decent understanding of all the bugs and weapons in the body used to fight them. It is important to choose a reference that has brief and concise descriptions of all the microbes so you don't waste your valuable time. For immunology, get Medical Microbiology and Immunology--Examination and Board Review (Levinson and Jawetz) or High-Yield Immunology. High-Yield Immunology is a fairly quick read and covers most of the high points for the exam. Levinson and Jawetz has a great section called "Brief Summaries of Medically Relevant Organisms" and a must-read 70-page section on immunology. Clinical Microbiology Made Ridiculously Simple will be your major resource for board review in microbiology; it can be a long read for step 1 review, but it’s well worth it.

Medical Microbiology & Immunology: Examination and Board Review by Levinson
*Clinical Microbiology Made Ridiculously Simple by Gladwin
High-Yield Immunology by Johnson

:::::PHARMACOLOGY:::::

This is the toughest call – there is not one "best" book. The same said above with micro/immuno applies to pharm. You want a reference that doesn't waste your time but gets to the point as this topic is high-yield on the USMLE step 1. Tables, outlines and index cards are very helpful in studying for pharm. Lippincott's Pharmacology has excellent illustrations and tables that are worth looking at. The book is cross-referenced to its brother, Lippincott 's Biochemistry. Johannsen's Pharm Cards are index cards highlighting the major drug/drug classes that are very useful. The index cards have great diagrams and charts. We recommend you use the pictures and tables in Lippincott's with Pharm Cards. If you are looking for good pharm questions, Katzung authors a board review book that has tons of them in the back. The text is good, but is too detailed and takes time to read. If you have been using the companion all year and are familiar with it, stick to it, it will be easy to go through what you've seen before. Again, know the section in First Aid COLD!

*Lippincotts's Illustrated Reviews Pharmacology by Harvey
Pharm Cards: A Review for Medical Students by Johannsen

Pharmacology: Examination and Board Review by Katzung

:::::PATHOLOGY:::::
This subject represents the foundation of your medical knowledge, and not surprisingly, the foundation of this exam. BRS Pathology is the best review book for pathology. Buy it early and use it along with every course The BRS path book does an outstanding job of taking the vast subject matter in pathology and presenting it in an easy-to-read outline format that highlights "key points" (there are literally small keys in the margins next to important tidbits of information). By May, you should have been through this book at least once. It is also worth your while to do the study questions at the end of each chapter. Finally, be familiar with the slides and path photos presented both in BRS and in First Aid; you will see slides similar to this on test day, so being familiar with these is another endeavor worth your time. Above all, be confident that your preparation in taking ICM and Pathology this year has provided you with a good foundation for preparing for this exam. You will find that this, too, is information that you will rapidly synthesize as you review it.
*BRS Pathology by Schneider
:::::PRACTICE QUESTIONS:::::
If there is anything that really needs to be stressed in this study aid, then it should be making time for sample questions. It is imperative that you get the "feel" for exam questions. Do as many questions as you can and look at the explanations. At a minimum, complete as much of Q-Bank as possible. Kaplan's tests are probably the most similar to the real board questions. You will learn that as you do more and more questions there are certain topics that are gone over multiple times. It is your duty to pay attention to these topics during your question taking and develop a firm understanding of them. The other books have flaws (too easy or too hard). The retired questions are great to get a hold of because they are past Step 1 questions. These questions are out of print, but they are around, look for them. There is also an excellent book of answers that goes along with the Underground questions. The NMS book has longer questions simulating Step 2 a little, but nevertheless it is a good source of questions. Do the practice question CD that comes with your Step 1 registration materials when you first begin to study, and do it again a day or two before you take Step 1 – it’s not uncommon to find repeats of these questions on the actual exam!

*Kaplan Services Q-Bank:

Full-length on-line practice tests, the standard questions that most students use. The Q-Bank should be saved for the month right before you take the exam. Highly recommended.
Review for USMLE I Step 1 Examination by NMS, Lazo:

USMLE-style questions with explained answers; the vignettes are good, although the questions tend to be pickier than the actual USMLE exam, and the explanations are long. There is a CD version of this NMS question book that students did not like as much as the book.

Board Simulator Series by Gruber:

Integrated organ-system approach to questions. Board Simulators include 5 books (Systems I and II

cover most of the organ systems) or a CD that has the same content as the 5 books. The Board

Simulators are more challenging than the boards), although with the right attitude, they are great to

learn from. Do not grade yourself (too discouraging). Overall, not recommended.

Retired NBME Basic Medical Sciences Test Items by NBME:

Outdated and difficult to find.

Appleton & Lange Review for the USMLE Step I by Barton
Full Length Practice Test for the USMLE by Stanley Zaslar

Putting Together a Schedule

Obviously, the more time you put into studying, the better the results you will most likely see. So if you are organized enough and willing, spend as much time as you feel necessary, and simply alter the schedule we are suggesting based on your own desired preparation time.

Keep in mind that this time of studying is really just a comprehensive review of material that you already know. You will not learn many things for the first time, though you will notice that as you synthesize information they may seem new since you finally make sense of them! At first it may seem as though you need to go through everything again and this may very well be true, especially for biochem, but the rate at which you relearn things is quite rapid, so don't panic.
As you plan your study time, it is important for you to establish your goals for the boards-to borrow terms from First Aid, do you want to just pass, to beat the mean, or to go for the gold. Your decision will be important in deciding how intensely you approach your studies. The following is a schedule for someone who wants to do well, but who wants to have a reasonable study schedule for about 3 weeks.

Before we begin, let's just lay out a couple of general principles:

• 
  Make your schedule and stick to it. Many have benefited from approaching studying for the boards as a job. Punch the clock for a set number of hours per day and then, provided you actually worked in that time, let yourself leave it behind when the time is up.
  
• 
  Include breaks in your schedule. This can be a grueling month of studying, so schedule in a day off per week, an hour a day for exercise, time to hang with friends and family, or whatever else you want to do. Your motivation level and overall efficiency will be enhanced by adequate rest periods.
  
• 
  Remember that First Aid for the USMLE Step 1 is your gold standard! Before you study each subject, spend a brief time reading over the high yield facts in First Aid, and return to it again when you are finished to emphasize the important tidbits. KNOW THIS BOOK INSIDE AND OUT!!! In a survey of the class of 2002 asking for the greatest piece of advice they could offer future Step 1 takers, the most popular answer was "memorize First Aid."
  
• 
  If you used a review book during the class, use it now. There are so many books from which to choose, so if you have one with which you are familiar, use that one.
  
• 
  Be sure to hit the large, important subjects (path, pharm, micro, physio, and biochem) more than once during your preparations. Hit them hard in the beginning for two days or so, then come back at some point in the last week for a 1 day speedy, thorough review. You will be amazed how much you pick up that second time through.
  
• 
  As has already been said, use practice tests to your advantage. Schedule them into your evening time or use them whenever you get tired of studying during the day. As the test approaches, try to do several back-to-back one hour blocks to ready yourself for the exam.
  
• 
  Don't completely blow off any subject. It is silly to miss some easy points in something like Biostatistics when the information can be picked up in just a little bit of time. At the minimum, at least read the high-yield facts in First Aid.
  
• 
  One last time for emphasis -- especially during those last couple days, be sure to come back to First Aid
  

A Sample Schedule

Its Saturday, 1 PM, and you just awoke from the post-exam party last night. What was the exam on? It doesn't matter, put that behind you, and.........relax. Yes, relax. Should you start studying for the boards? Go wild and take a weekend off. You deserve the break. See you Monday.

Monday morning: consider taking a practice exam to see where you stand. Pay special attention and note areas of obvious weakness.
Here is what we have to cover and how long it should probably take:

Topic	Estimated time	Comment
Behavioral Science	1 to 1.5 days	Actually tested and fairly easy questions you need to cash in on, but you have a book, Fadem (BRS), which is short and has questions.
Biochemistry	3-4 days	Perhaps the most tedious of the subjects review early (1-2 days) and late (1-2 days), saving the questions for the later time. Lippincott is a heroic effort, but an excellent resource, particularly if you used it before.
Physiology	4 days	High yield. Perhaps the most important subject. Again, review early and late. Know Costanzo, shockingly effective.
Anatomy/Histology	1-1.5 days	Honestly low yield. The focus should be on clinically useful stuff: which fractures relate to which nerves, winging of the scapula, etc. Radiographic images can be emphasized but generally stick to the basics; i.e. you see an x-ray with fracture at the midshaft of the humerus, what nerve is at risk? KNOW the basic X-rays in High Yield Anatomy
Embryology	0.5 days	Don't neglect it, but don't blow it out of proportion. First Aid stuff high-yield.
Pharmacology	3-4 days	Enormous volumes of material. Remember to think categorically. You have to know your autonomics. Know major side affects if they are bad, i.e. agranulocytosis, cardiotoxicity. A lot of people applaud the flip book.
Microbiology	2-3 days	Sorry guys, it's in there, even the worms, but not enough to justify slaving over them. Know the parasites in First Aid. Try to combine micro with your antibiotics review, they are related in real life and surprisingly on the boards too.
Immunology	1-2 days	Fairly good yield. Glance over immuno- deficiencies-in First Aid the day before the exam. Principles more than details.
Pathology	4-5 days	One of the big-hitters on the exam, should also be a big-hitter in your prep. Another subject you want to hit both early and late. The BRS path book (Schneider) is a time-tested favorite.

So, that is an approximate time schedule for the material you need to cover. Remember this is a test that reflects 2 years of hard work, so hours, though important, are of limited gain. Again, during the last couple of days, look at First Aid, review those areas with which you feel uncomfortable, take practice exams, or relax. If you have prepared diligently, your work is done.

Rejoice! The end is coming.

A Final Word

There is no magic bullet for success on the USMLE Step 1. Successful preparation boils down to three things.

1. Work hard and learn well in your M-II courses.

Students report that material tested on the USMLE exam was learned in class, not crammed at the end. Keep up, go to class, and stay mentally and physically healthy. A good M-II year is your best insurance policy for USMLE.

2. Use board review books along with your classes.

For most subjects, this means faithfully reviewing physiology and previewing pathology and pharmacology. For microbiology, neurology, and behavioral science, use their respective review books.

3. Be strategic in your Step 1 preparation.

For the intense USMLE study period in May/June, select standard board review materials that are well-regarded, make a reasonable schedule based on your goals, and stick to it.

We hope this guide will be helpful as you make your
first step of three to freedom!

BE FOCUSED!

BE CONFIDENT!

BE SMART!

DON'T WORRY!