My STEP 1 Experience

Foreword

Before we move ahead with my account on the unfathomable experience of USMLE step 1, let me brief you over what's the intention behind writing it: to make a critical scrutinty of the established ways of the prep and an honest assessment of one's inner potentials which often go underrated rendering people to making wrong choices. Confidence and hardwork are the key to this exam. It is as much a test of your fortitude, perseverance and manegement skills, as it is of your medical knowledge and intelligence. So let's work hard in liaison with our colleagues to accouter ourselves to take on this challenge in a more adept way than we can on our own. Here's one of the ways I can help.


My Experience: The Prep

I took up the following books [n stuff] for my prep:

Kaplan Qbook, First Aid 2006
Gross Anatomy - Hiyield + Netter's Atlas
NeuroAnatomy - Hiyield + Netter's Atlas
Embryo - Hiyield
Histo - Hiyield + Juncquiera's Atlas
Physiology - Kaplan
Pathophysiology and Pathology - Goljan 500 + Goljan Slides + Goljan Audio Lectures
Biochemistry and Molecular Biology - Kaplan
Genetics - Kaplan + DVD [Reichenbacher]
Biostats and Behavioral Science - Hiyield Biostat + BRS Behav.Sc. + Kaplan + DVD [Daugherty]
Pharmacology - Kaplan
Microbiology/Immunology - Kaplan

With all the other stuff that I had to take care of, including the research stuff, here is how I managed the aforementioned load:
Read 1 - all subjects [all books]
Read 2 - all subjects [the main book + multimedia] + kaplan Qbook
Read 3 - all subjects [the main book] + First Aid
UsmleWorld


My Experience: The Exam

The most extensively tested subjects [in descending order]
Biochemistry > Pharmacology > Pathology > Bacteriology > Behav.S

Pharmacology: was exceptionally hard. The questions were mostly targeting the following aspects of the subject:
1. Drug Drug Interactions
2. Pharmacokinetics and Pharmacodynamics
3. Alternatives to prototypes in conditions like renal failure/liver failure/senility/infancy/pregnancy
4. Drug Toxicities
Drug groups most vigorously assessed were:
Antivirals, Cancer Chemotherapy and the dreaded Immunopharmacology
Now my pharm is good but this stuff was just crazy.
This subject was a nightmare.

Biochemistry/Genetics: the most extensively questioned subject on my exam. To give you an idea, there were around 20 questions on Purine/Pyrimidine Metabolism alone. The focus was on the following aspects of the subject [in descending order]:
Metabolism > Genetics > Molecular Biology
Genetics was not the highlight of the exam as is perceived by all. But I am glad I was able to ace at whichever chunk of it was there.

Physiology: the graphs were everywhere and they were all new. Not one of them was from a review book. You know, stuff they coin up from the top of their heads. It wasn't hard but it was timetaking. Time management was the real bitch in the exam. The questions were either long or too complex in their graphic depiction. And that stays true for all the subjects. There were no physio questons requiring calculations [that was a breather].

Pathology/Pathophysiology: was easy, or maybe just all IMGz tend to focus too much on it for whichever reason, but as long as it helps you skim through a couple of blocks, its all good. Only when it impinges on other subjects, its a problem.
The systems were assessed in the following order of volume:
1. Endocrinology
2. Neurology
3. Pulmonology
4. Nephrology
5. Gastroentereology
6. Cardiology [n that was a surprise]
7. Hepatobiliary
8. Hematology [n that was a relief]
9. Dermatology [thank God!]

Biostats and Behav Sc.: There was very little biostat in the exam. A little bit of confidence interval n hardy-weinberg n stuff. Not much of SDz and Modes and true negatives n stuff.
Behav sc. was extensive, and scenarios were a butt-ache. They were all so confusing. This is the stuff you can best prepare for by either being in a hospital here or listening to Daugherty's DVD. CK's Ethics reviews may be very useful. A couple of stupid questions on developmental milestones were there just to give me a chance to recall my nephews and neices , cos i got so many of them in each age group, i owe it to them for keeping me from going thru the ordeal of memorizing those milestone charts in kaplan, which i m sure only a natural born pediatrician or a nerd can retain.

Anatomy n stuff: I scored the highest on histo in UW and yet it gave me a tough time in the exam. I was like, this wasnt even in Juncquiera, man! Embryo was almost negligible. Anatomy was purely clinical. Netter and hiyield's clinical correlates helped a great deal. Neuroanatomy was intervowen with Neurology and they made a good chunk of the exam.

Microbiology/Immunology: Bacteriology was tested in great detail. It was focusing more on the toxins and the clinical stuff than on the basic stuff like the pilis n capsules or even the classification. Parasito and Mycology were almost nonexistent. Immunology was a little rough, those CDz n stuff , but the clinical syndromes were not that bad.


My Suggestion:

Before getting started with the mammoth task of preparing for this exam, we need to be honest with ourselves. We need to assess where we stand and how we have to move on. How good or bad we are at medicine is pretty irrelevent as far as the outline of this prep goes, though you will need to make some necessary adjustments with respect to your academic standings but the basic course remains the same. And as long as you have the mettle to strike hard at it, you can ace this exam with God's gracious help.

Anatomy: Kaplan will suffice. Hiyield is better but its too lengthy. For someone who likes tailorwork, do kaplanz bulk and just the clinical correlates from hiyield. Netterz images will be helpful but time consuming.... if you choose to do it, make sure it doesnt spill out of first 2 reads. Embryo can b taken care of from kaplan or medesentials or First Aid. It is the only subject that you can shorten the prep of so as to be able to give other major subjects their due share.

Physiology: Kaplan is the only book that you really need to do in this subject. Don't bother about BRS. It's just a waste of time. Do Medessentials for graphs and reviewing.
Getting the concept is very important in physiology. If there's something that you dont comprehend well, check Ganong. But again, even Physio should not take too much of your time.

Biochemistry/Genetics/Molecular biology: Kaplan is enough for metabolism only if you had done your biochem really well in med school. How to assess that? Well what kaplan does is that it outlines the course of a subject for you, when the circle is formed, see how well your knowledge fills within the circumference. If there are bald spots, refer Lippincott. But as far as you know your stuff well within the parameters set by kaplan, you dont need to look out for anything else as far as this subject goes. Genetics is a major thorn in most ppls' side. IMGs usually abhor this subject an tend to do one of the two things: get anxious about it and overdo it [which is usually not a prob until it starts getting on your nerves n you begin to lose it], they fear it too much to go thru the real jist of the subject and end up doing it superficially [taking the coward's way out]. The best deal for Genetics, in my opinion, is to do Kaplan with DVD [Reichenbacher] and then do Medessentials well. There is some good stuff out there in the internet related to this subject, you know like summary charts n stuff. That will help but Medessentials will be the key.
Molecuar Biology is also much loathed in the IMG community. Do it well. I got loads of questions on it and they weren't easy. Kaplan will do the trick for you if u listen to the DVD alongwith it. Overall, a very important subject that IMGs usually dont feel confident about and are often actually weak at.

Microbiology / Immunology: This is also a very important and an extensively tested subject of the step 1 course. Doing bacteriology well is simply imperative for this exam. The clinical aspect of Microbiology overrides the basic science aspect of it and that's a relief, aint it? Toxins, Pathogenicity and pathogenesis, virulence and resistance, and microbial genetics must be mastered for this exam. Parasitology and Mycology didnt turn out to be that important in my exam, but I will stick with the rhetoric....Do these well, they are important! Virology, now that is one tough subject, aint it? IMGs suck out loud at it! So there's all the more need to target it. I found all aspects of virology thoroughly tested in the exam. Not to mention, you have to REALLY good at EVERYTHING regarding AIDS/HIV and Hepatitis. No question about it.
Where to do all that from? Kaplan's gonna take care of you. Micro/Immuno Kaplan is the best book in the series, although Jawetz is very good too but one only needs to do it if stuck. Mind you, Virus classification in Kaplan is terrible and you will need to get it from some place like medicalstudents.com.
I should take this opportunity here to warn you will find a lot of relevent material online, and most of it will appeal to you. Do not exhaust your energy and time on those. Some of the them are good, but the habit of collecting and reading such stuff can be a brain-drain. I personally found these to be very helpful: Medical Students Amnesia (brain101.info), Big Book of Virology (medicalstudents.com), Genetics charts that Talal gave to me (thanks to him) and Goljan 36.

Pharmacology: This subject remains the most difficult subject out there. Even if you think you are good at it, it will outdo you. No doubt! Take it as your big challenge!
Each and every drug, each and every side effect, each and every drug-drug interaction, each and every bit of info is absolutely essential in Pharmacology for this exam. Do not let First Aid fool you that it is going to be easy. Antimicrobials, Cancer Chemotherapy and Immunopharmacology, as hard as they are, happen to be the most indispensible of all the things that you will ever come across in the course. Do not cave in to the pressure. Pharmacology is the cornerstone to the success of this exam, cos lets face it, we all are pretty good at pathology and bacteriology, and decent at physio and embryo/histo , so that takes care of half of the questions. Its the Pharm and Biochem/Genetics that make the real difference in an IMGz prep. Use Kaplan but keep Lippincott/Katzung Review by your side and do refer it whenever you have to. Its a lot of hard work but it will not go in vain.

Pathophysiology/Pathology: The major bulk of the exam. These two will or atleast should comprise 40-50% of your prep time and you should well-versed on how to use it. I suggest Goljan 500 [High-yield Notes] for all those who can handle it. It is stupendously long to the point of being incommodious, but its great! Its absolutely the best compilation of facts I have ever come across. It is esoteric but it also covers the basic concept like no other. The grasp on basic pathophysiology is supreme and the way it bridges pathology with microbiology, immunology, physiology, biochemistry and genetics is la extra ordinaire! It will have a strainous effort but it will pay off, provided that you do it wisely. There will be times when one would tend to feel lost in its abyss of information, you will need to use BRS as a buoy to pull you out and to keep you abreast of the actual course of things. Some will argue that Kaplan can do the same as BRS. They're probably right, but as long as you're doing Goljan 500, you don't really have to worry about either one of those. Please do not bother about Goljan's Rapid Review! Its a waste of time and one would rather do BRS instead.
You will find it a delightfully invigorating experience to listen Goljan's lectures. That is the highlight of the whole prep! It will spellbind you and that is an understatement!
Garnish your prep with goljan's slides that you will need make sense of what Goljan is saying in his lecture.
Webpath is simply too much! Doing all of those slides will be a colossus but nevertheless helpful. I'd suggest you guys to make better use of time and do Kaplan Pathology Library instead.

Biostats/Behav.Sc: Behavioral Sc. is no longer an alienated subject for IMGz. It has been constantly assessed on the exam and IMGs have started giving heed to it.
Kaplan is an excellent book for the subject but it must be done with Daugherty's DVD. For ppl who may find it hard, should refer Hiyield Biostats for the troubling topics only. Biostats' formulas are a haunt and one should hakve fluency with them, but your knowledge of Ethics will be stringently tested. Their scenarios are oft confusing in UW and Qbook and same goes for the exam. Daugherty will help you there. For the milestones, memorize them as you like or simply take your chances and leave it.


USMLEWORLD vs KAPLAN QBANK

Choosing an online assessmet simulation can be a dilemma too. You will find mixed opinions and altering trends of popularity of either and you may end up choosing UW just cos its cheaper, well thats wise! But here's a comparison:
UW, the best thing abt it is that the questions are a lot harder than the real exam, so it prepares you to face real tough ones that will appear in the actual exam. Overestimation of the difficulty of this exam will help you pay more attention to minute details which one tends to overlook or forget along the way. UW questions tend to be shorter than Kaplan Qbank [ and Qbook for sure] and you are often able to finish blocks early, that's where u are misguided by thinking your time management is fine. The real exam has a lot of graphs and the questions are very long and you will find youself hustling in the last 5 questoins of each block if you are used to UW answering pattern.
Kaplan Qbank is as close as you are ever gonna get to the real exam without actually taking it. Its an excellent simulation and it costs more too. The questions are smarter and the explanations are better. But it doesnt give you the kick in the butt that some may need to instigate their anxiety-induced motivation.


FIRST AID vs KAPLAN MEDESSENTIALS

In the end, I will address the most important component of the USMLE step 1 PREP. The Pilot of the Prep!
This is where you have to ask yourself what do u wanna do with your prep. Take it to a higher level or notch it down after going through the seemingly unsurmountable drudgery of the 6-month prep.
First Aid is the kind of book that notches it down for when you have gone thru lecture notes n other reviews 3 times in the course of ur prep. It gives us an overview of the "most important" stuff from the course ,,, which actually means....it's an overview of the easiest stuff , stuff that you must be knowling well after 3 cumbersome reads of Kaplan Lecture Notes anyway. Who needs to revise stuff that he already remembers? Well, some do but what you really need is a revision that focuses on the stuff that you have the tendency of forgetting. All the esoteric stuff and marginal details that FA opts to shed off is what your exam questions thrive on! What's further devastating is that FA tends to give this notion that USMLE Step 1 is an easy exam. Well, it is not! And it's better to find that out during your prep than in your test. FA is a poor contender for the pilot spot for all these reasons and one more, simply that it is in text format, making it even more of a drag than it actually is. FA was designed and will remain so for the AMGs who just take a month's time to prepare for step 1, using kaplan qbank and first aid to pass! They dont have to score 90 plus. But we have to! That's where Kaplan Medessentials kicks in! It is an excellent book that takes care of all the real aspects of the final review of the prep. It has the best funnel effect a book can ever have on all the subjects and here's why i think so. ME has a lot of information packed into many charts which are very time-efficient and high-yield for final reviewing and DO NOT miss out on the important details that FA very convenienty does. ME has a lot of graphs making it an excellent tool for physiology and pharma prep, the figures are also very good. The best thing about ME is that after reading Kaplan lecture notes, you are delighted to find that all that you found important is already there in ME, something that you will otherwise have to jot down on FA if you choose to do it, whose arrangement of topics is very haphazard. That feature of ME keeps you from revising Kaplan Lecture Notes the 4th time during the UW/Qbank days. The last important thing about ME is that it DOES NOT give you this sham idea that USMLE Step 1 is an easy deal as FA's inane terseness would have you believe. It gives an honest drift of how rough the exam might get and at the same time gives an artful representation of all the stuff you need to score great. Yes it is lengthier and apparently acrimonious but its about one of those times when you've got to ask yourself....How hard can I hit it?

Thanks for reading,

Faiq Shaikh,
Research Scholar
UNC-CH Radiology

responses are welcome here in the comments section and/or at faiq.shaikh@hotmail.com