My Guide to the USMLE Step 1

I have been waiting to write this for 2 years. Part of being an organization addict means that when you face something as daunting as Step 1 and spend an inordinate amount of time learning about how to prepare for the test, you expect (hope) that your results line up with your expectations. Thankfully, the hard work, wife’s patience, and faith (or dumb luck) has yielded good results. Also, all links open in new page…so enjoy!

Disclaimer:  Since there are people I know in person who read this blog, and since there is some weird taboo where you don’t share your score unless you’re commiserating, competing, or just gloating, I’ve chosen to handle my credentials in the following way. Here is a link to my score report. You can choose to read it and say, yep, credible, or you can see the value and wisdom in my work and not go down that road to knowing too much. You’ve been warned, taboo dealt with, mostly. Moving on.

I think the two most influential authors on my mindset going into studying for Step 1 were David Allen and Tim Ferris. Allen’s GTD system, a large focus of this blog, really helped me stay on top of my responsibilities leading up to the big dance. Furthermore, I am drawn to the entire mindset of efficiency and productivity that his work engenders. Inefficiency literally gives me anxiety. Ferris takes this to a new level (and kneads in some broscience, which despite my doctor future, I indulge in way too much). Ferris’ work tends to revolve around the idea of “if you can measure it you can improve it.” This was a huge theme as I prepared for Step 1 because I was always looking for metrics to not only predict my score (an obsession of all students I think), but also to decide whether a modality was worth the investment. With that, if you have leisure time, i.e. its the beginning of 2nd year, I highly recommend the following 4 books, generally in this order. They are quick reads, especially since a significant portion don’t apply to you as a student or a future doctor. The life lessons though, and learning to apply them to the field of medicine, are pure gold:

The Guide

I would like to model my guide around 2 concepts from “The 4 – Hour Chef”. I think that keeping this framework at the forefront of your mind will ultimately serve you better than just the bullet points of what I did. If you follow these concepts, building a personalized study plan (perhaps based on my recommendations) will yield greater results than blindly following a template that took longer than I’m willing to admit to construct for my specific needs. On that note, I think the discussion threads on Student Doctor Network, while sometimes devolving into petty bickering, trolling, or the occasional rant, also served as great resources. There are only a limited number of study modalities out there, some very simple, some overly complex, and the best seem to be commonalities amongst high performers. Without further ado, here’s Ferris’ guide to mastering anything from cooking, to language, to in this case, the USMLE Step 1:

  • Deconstruction
  • Selection
  • Sequence
  • Stakes
  • Compression
  • Frequency
  • Encoding


what are the minimal learning units, the Lego blocks, I should be starting with?

A favorite quote of mine throughout the year was, “Everything’s fair game for Step 1”. While it may seem that way, there is a whole industry dedicated to making “High Yield” review material because despite the amount of fair game topics, Step 1 is full of trigger words, favorite diseases, themes, and motifs. I like to think that I know anatomy like a doctor, not an anatomist (or a surgeon I guess) because when you say knee injury, I know the 10 or so questions you are going to ask. Ankles usually invert, but if they evert, you chip your tibia. If you have a mastectomy, you’re going to get winging of the scapula and or Stewart-Treves syndrome. It’s relatively predictable.

The first minimum learning unit is normal function. If you know all that, you can talk the language of step 1, but you won’t be able to answer any questions. None really. Questions are so multidisciplinary that perfect knowledge of histology will get you no where. Conversely, without a good grasp on what you’re looking at, you can know all there is to know about metaplasia, but if you can’t identify Barret’s esophagus, you’re going to be staring at a slide with all your wasted potential. This is why doing well first year is a great way to skip having to relearn what you slept through. Sources like Firecracker do a great job of actually testing these basic science topics, and the rich explanations from sources like UWorld are usually enough to shore up any deficiencies. Pathoma also goes to great lengths to explain normal before diving into pathology. If you really don’t understand a concept, Wikipedia will usually suffice.

Next are patterns of pathogenesis. Knowing the APC pathway for colon cancer is very high yield because it is a multistep goldmine of multiple choice fodder. Every answer choice will be on topic as opposed to A-D of “KRAS mutation, cat, verb, and this image of a chair” Step 1 loves processes. Your own personal diagrams are probably the best, but since you don’t always have time, sources like Goljan’s “Rapid Review” do this for you. First Aid also has some great diagrams. Other random books may have some good diagrams (RR biochem comes to mind, as about 9/10 of the book is nowhere near HY, but some stuff ended up on my 31 page cheat sheet). The most helpful were again UWorld (and Kaplan to a lesser extent) because they would ask all the questions possible and keep showing the same diagram. It was very helpful to clip those diagrams, either with a program like Skitch (if they allowed screen grabs) or a camera or a pen and paper, and compile a separate note, especially if I was prone to getting stuff from that topic wrong.

Third, all diseases and their properties that can be put in a table are essential. In my experience, Kaplan “MedEssentials” did this the best. The book is all tables and charts and graphs. Kidney pathology comes to mind, as differences in light microscopy, EM, and immunoflorescence give away the disease. Again the theme is similar answer choices.

Fourth, Step 1 loves arrows. I was blessed to have a teacher who tortured us with these questions, but if not, I highly suggest making them for all pathophysiological concepts. UW and Kaplan cover a lot, but the practice of understand what goes up and down will pay off. There’s a trick that seemed to work on a lot of these questions: the right answer is unique by only one factor, usually from left to right. If for instance if there were 3 parameters there was a total of 12 permutations with the first column 4 up, 4 down. The next column had 2 up, 2 down, 2 up 2 down, and the last column was alternating. If by chance they didn’t follow this all inclusive model, an answer choice that was unique, say the only choice that had the first arrow down, was wrong. If it were right, it wouldn’t require you to know about the other two parameters, and that’s just no fun. For more hints on beating the test, see the end of this post.

Lastly, a key basic building block of knowledge is a large database of buzzwords, or more appropriately, buzz concepts (trademark pending). Sadly, currant jelly sputum is no longer vogue, but just like Plato’s world of forms transcend our world of substance, there are only so many ways a prompt can describe thick mucoid sputum. In the words of Goljan, “pigeons, cryptococcus!” Others are more concrete. Grey baby syndrome? Chloramphenacol! Anti-SSa and Anti-SSb? (It helps when the name of the disease is in the marker). Firecracker was hands down the best source for pounding in these facts. In fact, it was a better source than MCQs because the open ended format did not allow recall of prompts. As an aside, I think redoing MCQs more than once, and especially without significant time off, is useless. If your brain can’t remember the difference between Anti-mitochondrial antibody and Anti-smooth muscle, you can be sure it will notice the difference between the long prompt and the short one, or the one with a picture and the one without. Don’t let your brain associate anything except the correct concept. Bad brain. Naughty.


which 20% of the blocks should I focus on to get 80% or more of the outcome I want? 

Ok, the meat and potatoes. what should I spend my future self’s money on, plus 6.8% compounded annually. Here’s my official list of sources I used, in descending order of my perceived impact on grade:

That list is slightly misleading though. For instance, I think that Doctors in Training was nice to give me a once over, but that was with FA in hand, annotating, along with their workbook. DIT is dependent upon FA. Also, a source like Pathoma was technically redundant. It was also technically awesome since most pathology questions on the subject exam and Step 1 used information that I was thankful I knew solid thanks to Dr. Sattar. I thought that most pathology questions could be handled had I a photographic memory of Rapid Review. Perhaps this is a good time to mention a key learning concept: learn the same thing many times from multiple sources, especially if they are high yield. If you want to know what is high yield in RRs hundreds of pages, look for things it has in common with such tiny sources as Pathoma or BRS.


in what order should I learn the blocks? 

The general order of learning things is straightforward. Here’s my patent pending process (kudos to me for an awesome alliteration):

  • General overview. Like walking around a pool and dipping your toes in. This usually follows a logical order that may or may not be the best way to actually learn and retain the material.
  • Grouping. As mentioned, it’s best if done (correctly) by you, but you can pay others to do it neater and more colorful. Sharing (stealing) from other students is also appropriate (gunners gonna gun). At this point you are still usually just observing the information.
  • Recall. Whether that’s drawing it out over and over (hello urea cycle) or doing an ungodly amount of flashcards, it’s time to do work son!
  • Synthesis. This usually lags behind recall and connects distant concepts. It also checks your understanding for poorly integrated concepts during the grouping/recall phase. Here’s where MCQs, in volumes like donuts on cheat day, will serve you well.
  • Reduction repitition. I don’t think this gets enough credit. I knew all of Goljan’s jokes. I heard each Pathoma lecture 4 times throughout the year. Kaplan videos played while I did dishes.
  • Cramming. Don’t knock it. I remember writing all the translocations (I sucked at remembering them) over and over, walking in to the Pathology subject exam, and regurgitating them on my doodle sheet. That subsequently earned me 3 points I would have otherwise missed. FA has a great last minute cram section. Ironically, if you’re unprepared for the test, reading this section reminds you of everything you don’t know and shoots your anxiety into hyperventilation mode.


how do I set up stakes, create real consequences, and guarantee I follow the program?

This part seems clear. The stakes are your life! Ok maybe not that drastic, but we all know the importance of this test, for better or worse. In the least, it’s a foot in the door to show off your new suit, razor nicks, coffee stained teeth, and confuse cities because of the jet lag. If you’re game, and like games, a friendly competition may be worthy stakes. Or again, it might throw you into an anxiety spiral.

I think at this point I’ve given you the general outline of what I felt was important, and what tools were useful. Now, let’s talk about actually accomplishing that ridiculous plan you’ve doodled on whatever semi-flat surface you found with whatever writing utensil you had available. Here’s where Ferris’ CaFE model comes in.


can I encapsulate the most important 20% into an easily graspable one pager

Haha. No. I used to joke that as a physics major, I could write all the equations I needed to know on a 3×5, and derive the rest. Medicine is the opposite. Derivations, (i.e. thinking) is generally on the level of a shift supervisor at Starbucks (the simple life…with free coffee). The difference is the ridiculous amount of facts. With that, you are left with 2 options. First, you could use something like the Rapid Review section of FA. Conversely, you could keep a running list of concepts you don’t know. Stuff like the image of the urea cycle. The difference between CPS -I and CPS-II. (Running theme, I never felt comfortable with biochem). The pros are you don’t waste your time near game day reviewing stuff you know. The down side is that you might miss reviewing a HY topic you didn’t know you didn’t know in favor of some obscure topic like the ELEK test (thank you Kaplan, useless knowledge I will never use again). It also makes you feel really dumb while revising this 31 page document over a cup of coffee the morning of the test because one, you couldn’t sleep (duh) and two, you think you will magically learn something worthy (and not inadvertently push out something important, like how many chromosomes are in a human cell, which almost missed).


how frequently should I practice? Can I cram, and what should my schedule look like? What growing pains can I predict? What is the minimum effective dose (MED) for volume?

If you’re in medical school, the answer to this question is, in the words of John Dorian, “daily, nightly, and ever so rightly” (also the episode with the ass-pen). Seriously, it seems like you can’t study enough. As a general rule, during the year I did the whole one lecture equals 2 hours of studying. Add labs, lab prep, topics I felt uncomfortable on, etc, and the day was pretty packed. That said, exercise, hygiene, food, sleep, sex, and vegetation, in no particular order, were still done on a nightly and ever so rightly basis. Make your calendar, stick to it, roll with the punches, and you’ll be surprised at how much you can get done (plus, if you’re on this blog, learn some basics of the GTD system and optimize your workflow to squeeze a few drops of time for number four on that list (or number five, wink wink, nudge nudge).

When it came to dedicated time, the same principles applied. In fact, I felt like I had more free time during that time. Perhaps it was due to my need to watch old episodes of Futurama after a 12+ hour day of studying, but I indulged my need to decompress much more during that time than throughout the year. Carrot cake also helped.

As for the actual frequency of reviewing topics, I tried to maximize the time between iterations, with a final compressed run through at the end. For instance, I power read FA at the beginning of my dedicated time. Then I wen through each topic. over 3 weeks. On one day I would do RR’s RBC section and Pathoma’s and FA’s WBC section, then switch on the next day. I needed 2 days to get through blood, so might as well optimize how many times I saw the information. By this time, I had banked all of the Lite Mode of Firecracker, so I was doing whatever questions they gave me. I also did UW on random 46Q blocks. I chose tutor mode, but for people struggling to finish in time, timed mode is more appropriate. I then redid all my missed UW questions (never got around to doing missed Kaplan Questions) during the week leading up to the test. During that week I again did a FA run through, along with using the Lange Pharm cards. Finally, on the last day, I reviewed the FA Rapid Review section and my 31 page shame pamphlet of stupidity (I played sports as a kid, so derogatory and demeaning coaching is helpful…I might have a future in surgery).


how do I anchor the new material to what I already know for rapid recall?

I think this topic is highly personal. Whether it’s Meyer Briggs tests or a shaman fortune teller, you should know the answer to this by now. What’s worked thus far? Personally, I can connect concepts easily, but I can’t memorize facts at all. Firecracker was essential for this. Others need to mind map. Others like Picmonics and books like CMMRS because goofy doodles solidify tough concepts (and I imagine make explaining things to patients a bit awkward…”so you have a deficiency in the enzyme, hold on, the mnemonic was ordinarily careless crappers…)

My Timeline

It seems like even after knowing everything about what’s in the test and the different tools available, a lot of people finally get stuck making a workable schedule. In the end, you need to find what works for your and accomplishes your goals. I had originally scheduled a review of missed Kaplan questions, and due to laziness (need of relaxation?) I pretty much cancelled that and spread other stuff out accordingly. Here was my basic game plan:

  • Summer of MS1 to Test, do Firecracker Lite Mode (no new stuff) every f@#$ing day (except test weeks)
  • August to winter break, focus on schoolwork
  • Winter break, read FA cover to cover start Kaplan Q bank 46Q random annotating into FA
  • Winter to spring break, continue focus on school work and do 1 Kaplan 46Q/day, more on weekend if time permits
  • Spring break, do DIT in 10 days (12-14hrs/day of videos @ 1.3x while doing workbook and annotating into FA). Also finish Kaplan Q bank (and cry Sunday night before realizing you wasted your last “spring break” studying)
  • Spring break until final exams, do school stuff during week, old NBMEs on weekends. If time permitted, blow through HY books (Micro, Immuno, Neuroanatomy, Embryo). Also get through FA cover to cover again (wanted 2x…only did once)
  • Schedule appropriately for each Subject exam. Do Pathoma over weekend before Pathology subject exam. Don’t care about CBSE exam (this was 17pts below my actual score…anyone that says it predicts Step 1 doesn’t understand the value of a good study strategy)
  • Day of Pathology subject exam until Step 1
    • Divide FA, Pathoma (reading only), Rapid Review equally between 3 weeks, leaving one week + weekend to review missed questions
    • Divide UW amond 3 weeks, max/day of 4 blocks (took me 2hrs/block, ~30mins/46Qs, 1.5 hrs review. I don’t mess around with question blocks. You know it or you don’t, move on, then review)
    • Keep doing Firecracker daily, and if time permits, Lange Pharm cards daily
    • During last week, do all flagged questions from UW (flag all guesses or “great” questions along with your missed questions. I ended up with about 55% flagged). Keep a compilation of notes on stuff you still miss. Mine was 31 pages
    • Last 2 days, plow through FA, stopping on anything that catches your eye. Review 31 page “you’re a failure because you still don’t know this much” list. If you want, look at FA’s Rapid Review section
  • Night before exam, eat carb heave meal, take diphenhydromine, set 11 alarms and have all your friends and family give you wake up/encouragement calls. Cry (manly)
  • Day of exam, eat breakfast, dry heave, drink coffee, whatever you do don’t look at anything (ok equations are allowed)
    • Bonus! exam snacks were yogurt bits and trail mix, favorite cliff bars, and power aide (basically anything that saved me from needing to poop)

Hopefully this utterly cathartic post has helped you formulate your plan of attack. It’s doable. Start early. Work hard. Measure. Adjust. Step back and breath. You can do it!

Note: some people who know me point out that I actually had two months, not one, to prepare. This is because I tore a disc in my spine, spent a week and a half in the worst agony of my life on a constipated drug trip (opiate prescriptions need appropriate stool softeners), had a microdiscectomy, moved apartments, took the vacation I had planned after Step 1, then came back and actually did the above schedule. To this, I answer: If I hadn’t taken that break, my sanity post step 1 might be worthy of commitment (that vacation, while anxiety ridden, was nice) but I honestly feel like I forgot some stuff and never relearned it. You don’t run a marathon (and after back surgery neither do I…yet) and stop 100m before the finish line (crap yourself), then sprint. Ideally, you’d like to ramp up to spinal tap 11, rock the test, and be done.

Bonus: Beating the test

I want to highlight a few things that I’ve noticed about MCQ tests in general and Step 1 in specific that when all else fails, perhaps you can fudge your way to the right answer. No penalty for guessing!

  • “Which one of these is not like the other” is usually right
  • 2 right answers are both wrong. Think about it.
  • Use the idea of Likelihood Ratios. Look at the answer choices, start reading, make a hypothesis, and use the rest of the prompt to either solidify it or talk you out of it. If we’re talking about nerve injuries (choices include Long Throacic Nerve, Thoracodosal nerve, Vagus Nerve, etc) and the prompt says protrusion of the scapula, it’s LTN. Your LR+ is peaked. It would take an act of God to talk you out of that choice.
  • Specific findings are specific. Don’t be talked out of a right answer because of a lot of blabbing. Patients with an 8;14 translocation have Burkitt’s…no matter how much they try to tell you otherwise
  • Long lists of choices (The A-J instead of A-E) don’t want you to think. Pick the answer if you know it. If not, guess, and move on. No staring will divine the answer.
  • Pertinent negatives matter. A patient would be hard pressed to have RHF without signs of edema. Conversely, if they give you negatives, it’s for a reason
  • Pertinent positives (I don’t think those exist) also matter. No one with a BMI of 20 is obese.
  • Novel ideas (a new drug was discovered…) are hinting at a very basic underlying concept. Name that concept, answer the question. “Oh, they are asking about the difference between muscarinic and nicotinic receptors, that’s easy.”
  • Don’t change answers unless you realize you messed up. Changing because you feel like its definitely probably this instead of that means you definitely don’t know, so just go with your gut, which by definition was your first choice. Guts don’t second guess.
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6 comments on “My Guide to the USMLE Step 1
  1. Obby dobby says:

    Thanks alot mark.
    your experience, methodology is much appreciated.

    P.S. after going through i can say it ain’t dumb luck just had work. hard work & hard work

  2. hank says:

    Hey I’m wondering if you had any thoughts about firecracker lite mode (which you used?) versus the full program?

    • Mark says:

      I think we touched base on reddit right? If not let me know if that’s wasn’t you. I need to do a longer post about firecracker,but there’s great discussion on SDN

  3. Stylus says:

    Thanks mark for a detailed review and helping us prepare a good study guide. I did not know about firecracker so far and I think it may end up to be the best thing that I could have come across (just browsed…not tried yet).
    You mentioned “selected kaplan lectures”. can you pls elaborate on this. Also i would greatly appreciate if you could provide your study resources by subject ….(for example was FA + firecracker + DIT enough for anatomy)…assuming kaplan qbank and UW as default for all subjects)

    anatomy –
    behavioral sciences –
    biochemistry –
    microbiology –
    immunology –
    pathology –
    pharmacology –
    physiology –
    genetics –
    aging, nutrition –
    molecular and cell biology –
    epidemiology, medical ethics –


  4. Owen Sanders says:

    Awesome post! When I read 4 Hour Chef last summer, my first thought was “I should really apply this methodology to the USMLE when I take it.” Now I guess I don’t have to. Thanks!

  5. […] Managing Medicine USMLE Step 1 Guide […]

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