Step 1 aidsMichael 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 pattern-recognition 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 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?

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