Step 1 aids
Michael Adams
Step 1 is a very large set of associations
between groups of keywords and answers
• This is not a test of complex reasoning; this is a test of patternrecognition and multiple choice test-taking IQ
• You must recognize the disease from the group of keywords in the
stem
• Then, you must remember some factoid about that disease
A few examples of what I mean…
• "Marfanoid"
has multiple endocrine neoplasia type 2
• "25 year old man...BMI of 19"
 spontaneous pneumothorax
• "Recently recovered from sinusitis...now feels lethargic and short of
breath"
 has G6PD (and was given sulfa abx which caused hemolytic crisis)
Some conclusions:
• You don’t need to be able to recall the name of some specific test or
enzyme unassisted
• Instead, you must merely be able to recognize it
• Because of this, drilling pathways or very detail-oriented flashcards is
often unnecessary
• Recognizing the disease from the keywords in the question gets you
most of the way to the answer
For example:
• A previously healthy 48-year-old man comes to the physician because
of fever and cough for 2 days. He attended a convention 10 days ago,
and two of his friends who stayed in the same hotel have similar
symptoms. His temperature is 38.3°C (101°F), pulse is 76/min,
respirations are 20/min, and blood pressure is 130/70 mmHg.
Crackles are heard over the right lung base. A chest x-ray shows a
patchy infiltrate in the right lower lobe. A Gram stain of sputum
shows segmented neutrophils and small gram-negative rods that stain
poorly. A sputum culture grows opal-like colonies on yeast extract.
Which of the following is the most likely causal organism?
For example:
• A previously healthy 48-year-old man comes to the physician because
of
for 2 days. He attended a
fever and cough
convention 10 days ago, and two of his friends who stayed in
the same hotel have similar symptoms. His temperature is 38.3°C
(101°F), pulse is 76/min, respirations are 20/min, and blood pressure
is 130/70 mmHg. Crackles are heard over the right lung base. A chest
x-ray shows a patchy infiltrate in the right lower lobe. A Gram stain of
sputum shows segmented neutrophils and small gram-negative rods
that stain poorly. A sputum culture grows opal-like colonies on yeast
extract. Which of the following is the most likely causal organism?
There are tons of details in that question, and if
you knew every fact about legionella that’d be
great
• BUT all you really need to know is that “convention”=Legionella
So why is Step 1 so hard?
• Because there are a probably thousands of associations you must
know
• Not all of the keywords are as easy to recognize as in the example
before
Knowing how Step 1 works, let’s examine the
study aids
• Qbanks: UWorld, USMLErx, Kaplan
• UWorld: most realistic simulation of the exam. Buy this. Do every
question. Most expensive (>$400 for the year-long subscription)
• Kaplan/USMLErx: good sources of additional questions. Much
cheaper
• In both cases, the questions are often too detail-oriented. E.g. picking the
right answer for a Kaplan question requiring you know at what creatinine
level Metformin might be contraindicated.
• They both cover topic areas UWorld doesn’t; Kaplan has First Aid page
numbers
When using Qbanks…
• Examine every single wrong answer, and think about what would it
have taken for that to have been the right answer
• Mark the questions as you go that you guess on
• Budget lots of time to review your wrong answers
Books
• There are tons of books. You do not need, and will not have time for,
most of them.
• Get a copy of First Aid. It shows you what you need to know
• Do not spend too much time carefully poring over its pages,
convincing yourself you’re memorizing the material in it
• What counts is your ability to do practice questions
Doctors In Training
• A full video review course of med school + limited additional
questions + suggested study schedule
• Can take weeks to go through videos
• This is for people who really want external structure for their study
• Often, people just make their own schedules
• $825 + $200/week if you need extensions
Pathoma
• Short videos of high-yield topics—35+ hours in total (much shorter
than DIT)
• Universally renowned for clarity—super easy to follow and
understand
• ~$100
Picmonic
• Step 1 flashcards with a twist—lots of colorful, wacky drawings, as a
mnemonic in picture form
• Study them the same way you normally study flashcards
• $25/month, $250/year
• It works for some people, not for others
Firecracker
• Factoids and flashcards for every aspect of First Aid (even has page
numbers)
• The key idea is that doing a small number of flashcards over a long
period of time is extremely efficient for memorizing and retaining
facts. An algorithm automatically figures out which flashcards for you
to study each day
• Cheap--~$20/month
• To get the most out of it, you absolutely have to do this over a long
period of time and do flashcards every day
NBME practice exams
• ~$65 for 4 sets of ~44 questions each
• Most realistic
• Limited feedback—extended feedback ($10 extra) tells you what you
got wrong, doesn’t give right answer or any explanations
• HOWEVER…google any part of any question and you’ll find forums
where people give their answer and their reasoning
• People have extensively screencaptured most of these exams, and most will
be found on scribd
• People have also written entire answer keys
More on NBME practice exams…
• They claim to predict your score—this is not entirely true
• This will freak you out regardless
• DO NOT GET THE SCORE PREDICTION with a week to go before your
test—that’s too late to feel like you can do anything about it
• It’ll be nearly impossible to adjust your clinical year schedule and try
to put off step 1 if you don’t like your predicted score
• Truly, sometimes you’re better off not knowing so you can walk in
confident on test day
Time spent watching videos vs. doing
questions
• Watching videos/reading books feels great—you feel like you’re
learning, you feel like you’re understanding…
• It’s NOT THE SAME as actually doing questions
• Most people say they wished they’d spent more time doing questions
When to take Step 1
• Most people do it after 4-6 weeks of fulltime studying
• Most people say afterwards that their last week of studying was not
nearly as productive—that they were already going insane from 5
weeks of solitary confinement, etc.
• 2 months of study time is probably WAY too much
Study schedules
• Don’t be too ambitious—it often takes an entire half day or more to
do and fully understand 90 qbank questions
• Give yourself time off for sanity purposes
Final thoughts
• Step 1 is a highly trainable endeavor
• Most of your time should be spent doing questions
• Do not try to use too many resources—pick 1 or 2, and stick with that