USMLE Step 1:
The biggest problem with Step 1 is the amount of information to cover and memorize. The only way to succeed in retaining such amounts is through spaced repetition. Hence you see the extreme number of passes over First Aid (FA) and the UWorld Question Bank (UW).
The number of FA passes mentioned below doesn’t take into account any reading of FA I used to do for the university exams.
I usually recommend people to plan way in advance. When planning your studying schedule, start from the exam date and go backwards, giving yourself a reasonable amount of time to go over everything you want. This is always the best way to plan (just like for university exams but on a much larger scale). Don’t forget to include catch up days in your plan (free days to catch up to your plan), because unfortunately, however reasonable a plan is, it is very difficult to follow it perfectly.
As you will see in the plan below, the number of study hours should increase gradually. Just like physical training, you need to build stamina and endurance gradually in order to gain the ability to study for hours on end close to your exam date.
The most difficult thing about the USMLE Step 1 is the long and draining preparation, not the test itself. Once you go through months of prep solving thousands of Step 1 style questions, the exam itself is doable. Try to keep that in mind.
Some have asked me about finding motivation to study, and the reality is that nothing I will say will give you enough motivation to study for months. You must find your own reasons. Literally sit down with yourself and think about the reasons you want to do the Step 1, and answers like to do residency in the US are not enough, go deeper than that, and convince yourself that this is what you want to do, and you’re not just doing it because everyone else is. In the end, it is important to have your intentions or niyyah well-defined, and whenever you do anything with the right intentions for the right cause Allah will make it easy and reward you upon your efforts.
This is my personal timeline with minor modifications for clarity.
FA 1st pass: Priority is getting familiar with the concepts in FA using extra resources if necessary (e.g. pathoma, youtube, google, khan academy, BRS physiology, Kaplan, etc.). The objective is to understand any new or difficult ideas mentioned in FA with minimal memorization. Timeline: 3-4 months during academic year. [Approx. 12-15 pages a day, 3 days a week]
FA 2nd pass: Increased emphasis on memorization while revisiting the different ideas in the book. Timeline: 5 weeks during the summer (can also be done 10 weeks during the academic year). [Approx. 20 pages a day 6 days a week during the summer OR 10 pages a day, 6 days a week during the academic year]
UW 1st and FA 3rd passes: For the next 6-7 weeks, I was doing UW for the first time and FA for the third time, dividing my days between both (details in the comments below). Timeline: 6-7 weeks during the summer. a. UW 1st pass: Answering mode: tutor and untimed. Finished systems first, then went on to basics (didn’t do the questions randomly). Example: Under any system (say Gastro) I would choose: Anatomy, Embryology, Histology, Physiology, Pathology, Pathophysiology, and Pharmacology (basically following how the chapter was organized in First Aid). I would leave out the remaining subjects under Gastro (e.g. Biostatistics, Microbiology, Biochemistry, etc.) to be done separately later on according to First Aid’s basic subjects' chapters after finishing the systems. Once I solved a question, there were one of 5 scenarios: - Answered the question incorrectly. Repeated under “incorrects”. - Answered the question correctly by chance or without confidence. Marked for repetition. - Answered the question correctly with confidence, but wanted to repeat for: 1) a very nice question that really challenged my thought process, 2) some concepts were very nicely described in the explanation and I wanted to read it from there again, or, 3) the explanation summarizes multiple diseases in a very nice manner, and I wished to read it in the same way again. Marked for repetition. - Answered the question correctly with confidence, and apart from a small idea that is new, I felt comfortable with the question, explanations and concepts described. Wrote that new idea in my FA/Created UW flash cards. Did not mark or repeat the question. - Answered the question correctly with confidence, and after reading the explanations I felt comfortable potentially answering similar questions in the real exam without going over the same material again (usually the explanation to these questions are covered in FA). Highlighted in FA. Did not mark or repeat. b. FA 3rd pass: Familiar with most concepts by now, trying not to leave a page without having it memorized. [Approx. 60 questions and 15 pages a day, 6 days a week]
UW 2nd pass: I only repeated the marked and incorrect questions (as described above, which for me added up to around 1800 questions). Timeline: 3-4 weeks during the summer. [Approx. 100 questions a day, 6 days a week]
FA 4th pass: Last review. Brushing up on the knowledge and rememorizing the dry facts one last time. Timeline: 2 weeks. [Approx. 50 pages a day, 6 days a week]
As you can see, the bulk of studying was done throughout the summer break. Based on the experiences I have witnessed; I believe that summer studying is much more productive and valuable compared to studying throughout the academic year.
As you can see in the timeline above, I believe that for most students, 4th year and the summer between 4th and 5th year are the best time to dedicate your studying for Step 1, with the exam ideally being at the end of the summer. If possible, DO NOT WAIT TILL THE SUMMER AFTER 4th YEAR TO START. Your studying likely will continue to drag along throughout 5th year.
Recommendation: Every time you start reading FA, start reading from the systems then read the basics. Rationale: we are much more familiar with the systems than we are with the basics. This allows us to read through and understand the systems a lot faster than the basics. The faster pace gives us a confidence boost as we finish more than half the book before having to go over the dry and somewhat unfamiliar basics [the order I used to follow with minor changes every pass, keeping in mind that I always wanted to go over the things I am weakest in towards the end: Basic pathology > Systems from strongest to weakest ending with neurosciences and psychiatry > Basic pharmacology > Immunology > Biochemistry > Microbiology > Public Health].
Recommendation: Read FA cover to cover 1-2 times before starting UW. This is an arguable point as many of my successful colleagues have approached integrating UW differently. Rationale: FA is the primary resource that contains most of the information required to perform well on Step 1. UW is an exceptional resource that allows you to understand some of the hidden FA concepts and adds to the knowledge provided by FA. Without knowing the content of FA (by going over it 1-2 times), how will you know what to do with the plethora of information provided in UW? You will find yourself writing down notes from UW and later realizing that these notes are already mentioned in FA, thus, wasting valuable time.
A resource that I have been specifically asked about is “Boards and Beyond”. I personally have no experience with it, however, if you are someone who prefers to learn by watching videos/listening to lectures then it seems like a good idea to do it early on (before or with your first FA pass) to help you understand the content of FA.
To further utilize the spaced repetition theory, I integrated my 1st UW and 3rd FA passes as follows: I divided my days into FA reading/memorization in the mornings, and then UW questions in the afternoons and evenings. However, I would only read the chapter from FA after completing its questions in UW. The rationale behind this was to attempt to answer the questions without having the information fresh in my mind, which I believed would help develop my question solving skills, and it would space my exposure to all the topics over a longer period, for longer retention.
Recommendation: Solve UW more than once and make that last time within 2 months of your exam. Some people write down extensive notes while solving UW the first time and start to focus their time on reading those notes instead of answering the questions again. Rationale: practicing question solving is a valuable ability for these board exams, and doing the questions again not only reinforces that material for you but also improves your question answering abilities. Try to have a balance between note writing and question solving.
NBMEs and UWSAs: in total, I ended up doing 3 NBMEs (1 in the university early on and 2 online – forms 15 and 18), and 1 UWSA (form 1). I heard there’s a trend in our university to do all NBMEs for more practice. I can see how that may help, but if you are tight on time – like I was, I don’t think this should be a priority, especially if you are reaching/exceeding your target score on your NBMEs.
Speaking of target scores, decide on a reasonable target score based on the data available for the specialty you are interested in (e.g. Charting Outcomes for IMGs on NRMP.org). Yes, we all want to score the highest possible Step 1 score, but at the end of the day, you also want to balance your time with the other exams, securing electives, doing research, or whatever else you want to spend your time doing. If you aren’t sure of the specialty yet then you probably should target a reasonably high score that would allow you to be competitive regardless of specialty, and eventually your score may help you decide.
Again, try to decide on an exam date from the beginning and plan all of your studying accordingly (I knew when my exam date would be more than 7 months in advance, I ended up delaying my exam date by one week only). One very tricky thing about this exam is the ability to choose your own exam date. I have seen way too many people go into the vicious cycle of delaying the exam. We can never predict what life circumstances will arise in the upcoming year, but until and unless something has really interrupted your studying, delaying the test date should be the last thing on your mind. Again, it’s not the end of the world if you had to delay a few weeks, what I am trying to emphasize here is to always keep this as a last resort.
For the students who haven’t yet started 4th year, if you are serious about taking the Step 1, figure out who your study buddy for Step 1 will be (you two should understand each other very well) and sit down and lay out a plan together. You don’t have to study together if you don’t want to, but having someone that is serious and dedicated to motivate, follow up, and suffer with you is a must. If you are excited about studying this upcoming long summer break, I would recommend you spend a couple of hours a day (or something like 3 hours a day 3 days a week) familiarizing yourself with FA, or maybe watching Boards and Beyond and Pathoma. I would also recommend you utilize this long break doing other things that will help your residency application in the future (whether that’s research, work experiences or significant volunteering). Keep in mind as you are planning your timeline for future studying that summer breaks won’t be as long starting from next year, so you may have to start studying earlier than in the timeline above.
My intention is not to discourage anyone who isn’t following the above timeline. At the end of the day it is my personal experience. We have extremely successful examples of colleagues and seniors who managed all their exams during internship. But I am sure they all wished they had been more serious about Step 1 and finished it early on. Keep at it.
On the topic of nationals from the banned countries: I can only imagine how frustrating this is to you and I hope everything resolves soon. The question is whether you should consider taking the Step 1 or not. My answer will depend on which year you are. If you haven’t started clerkships yet, then I highly encourage you to take a leap of faith and finish the exam early (AKA by the beginning of 5th year). Rationale: During fourth year, there aren’t any other board exams that you can take, so might as well get this out of the way. Your medical knowledge and self-confidence will increase significantly, and your appreciation for medicine as a field will grow. On top of all that, a passing Step 1 score is valid for 7 years, so you will have 7 years to complete your Step 2 CK and CS and become ECFMG certified (a requirement for most specialties if you are interested in doing a fellowship in the US).
Do NOT feel disheartened when you come across things that you have forgotten. This is very normal throughout the process and happens to everyone along the way.
Over the course of your preparation, I would recommend leaving one day a week to spend with your family and friends away from studying (or whatever it is you enjoy spending your time doing). This will help you re-energize and re-focus and start the following week strong, and hopefully would keep you in the right frame of mind. In my own schedule, I only had half Fridays off, and in many instances, I found myself using that half day to catch up to my plan (didn’t include catch up days when I was planning!), would definitely recommend against that.
Making one recommended plan for everyone is unreasonable. I like to say that there’s no one correct way to prepare for this exam, and what works for me may not work for you. Read and hear other people’s experiences and opinions and make a timeline and plan that works for you.