Red Text Bullet Points:

If you dont feel like reading the lengthy text, here are the main points from each section:

If you plan to start studying for Step 1 in the summer: review the material from MS1 first, especially physiology.
Doing well in MS2 is the single most important factor in getting a great score on Step 1. My school taught me
very well in regards to Step 1 material with only minor gaps to fill.
Under no circumstances should USMLE World be used prior to spring break because the most value comes from
the first pass. Use USMLE-Rx and/or Kaplan banks in MS2 along with your classes and/or in a randomized testing
fashion prior to starting UW.
First Aid, USMLE World, + Pathoma, + Rapid Review Pathology are all you need. Avoid resource overload.
Since most people study four weeks for Step 1, aim to finish and review 3 USMLE World Blocks and 2 chapters of
First Aid per day, taking 1 NBME assessment per week to gauge your progress.
Though memorization of minutia is the key to getting above a 240 on Step 1, avoid annotating First Aid with
every small fact in UW. Incorporate UW learning objectives and concepts you do not understand first, then facts
you feel to be important.
USMLE World should always be used in a randomized timed fashion during your dedicated study period.
USMLE World percentages should not be obsessed over since students use the question bank in different modes
during different periods of time. Closer to Step 1, look at your recent percentages as an indication of how well
you retain material over the long term. Your UW percentage has almost no correlation to your Step 1 score.
NBME 13 should be used as a baseline; NBME 15-17 should be used to test your knowledge. The average of
NBME 16and17 +5 points can be used as a score predictor. Keep in mind Step 1 is much harder and different
compared to any NBME assessment.
While NBME assessment questions can be intentionally vague, USMLE World questions typically have one crucial
detail which makes a single answer choice superior to others.
Knowing essential lab values (BMP, CBC, A/VBG) will make life easier by cutting down frantic searching.
Burnout and/or boredom will inevitably occur during your study period. Take at least half the afternoon off and
relax before resuming studying.

When to start preparing?

You can start studying at any point after MS1. I chose to start studying in July after MS1 because I knew the score I was
aiming for would need a significant amount of time and effort, so it would be better to start preparing early. If you are
planning to start studying for Step 1 in the summer, please review the material from MS1 first, especially physiology. If
you have no intentions of studying in the summer before MS2, enjoy your time off!

Essential Principles:
1. DO WELL IN MS2! The more time you put into doing well in class, the easier it will be to review for Step 1.
2. KNOW YOUR PHYSIOLOGY INSIDE AND OUT! I dont know how many times this should be emphasized.
3. IT IS NOT WHAT IS CORRECT: IT IS WHAT IS MOST LIKELY! Just because an answer is correct does not mean that
it is what the examiners are looking for in that particular question.
4. MEMORIZATION APPLICATION UNDERSTANDING!
5. REPETITION: CONSTANTLY REVIEW PAST MATERIAL!

Your school and Step 1:

There are a lot of horror stories on the internet about schools which dont teach material well so students are thrust into
their study period with significant deficits and end up doing poorly on Step 1. I dont think any school has a perfect
overlap but my school taught me board material very well (when using First Aid, USMLE World and Pathoma for
comparison). Some of what we learn is over-emphasized and some subjects are not covered.

When to take Step 1?

The amount of time needed to study for Step 1 depends on many factors: how much youve prepared during MS2, your
performance on the CBSE, your target score, if youre in the MD/PhD track, etc. Most people will take Step 1
approximately 4 weeks after the CBSE and enjoy a full week off before MS3 orientation. I felt that after 5 weeks I was
not retaining a lot of information through First Aid passes or UW notes. Take Step 1 at least one week before beginning
MS3, which should work out to a total of 4 or 5 weeks to study for the exam. More time spent studying does not always
correlate with a better score and can actually be harmful as you begin to forget material.

Resources Used:
First Aid and USMLE World: these are the only resources you will truly need. If necessary, Pathoma and Rapid Review
Pathology can also be added. Do not give in to resource overload! Most people will put Pathoma among the essential
resources, but I found that after doing Pathoma three or four times during the school year it contained the basic of the
basic; only one pass is truly needed during the dedicated period since First Aid encompasses most of the information
presented. I found that in the time I watched a Doctors in Training video, I could have done twice the material reading
from First Aid. While it is true that DIT offers information not seen in First Aid via multiple source integration and errata
correction, of the videos I watched I did not feel this extra information was overtly important. You may like DIT if you
cannot sit down and read chapters of First Aid for hours on end.

Step 1 Schedule in MS2:

The Step 1 study schedule I used during MS2 is in a folder called STEP 1 MS2. Simply put, supplementing coursework
with First Aid is not only easy to do but will expose you repeatedly to what you should remember about the subject.
With repetition and use of question banks you will gain an understanding of the material. If you are studying for Step 1
during MS2 on a subject you have not yet covered, place an emphasis on memorizing mnemonics and
keywords/buzzwords first. Goljans audio lectures are absolutely amazing and should be on a constant loop throughout
MS2. He integrates many subjects into Pathology and makes connections in ways most people dont think of. Some of
the information is outdated but the general principles are timeless.

Step 1 Schedule:
I created an Excel file containing two Step 1 schedule sheets: Step 1 Schedule Template. You can see how I studied for
Step 1 in half-hour increments: Step 1 Schedule. On the internet I found a four-week schedule someone made:
usmle-calendar. Doctors in Training offers their own schedule and scheduling service that you may want to look at.
However you choose to create your schedule, you will probably have to do three full blocks of USMLE World, review
three blocks, and study a substantial portion of First Aid (or DIT videos) every day until your test, assuming you wont do
multiple passes of UW.

Practice Exams:
There are many services that offer practice exams. The most commonly used are the USMLE World Self Assessments
(UWSA) 1 and 2, along with the official NBME Practice exams 11, 12, 13, 15, 16, and recently added 17. The latter NBME

exams should be taken prior to your exam even at the expense of not finishing USMLE World. I say this because if your
goal is a 235 and youve been scoring around 233-237 on NBMEs with 85% of the bank complete, youve hit your target
goal and there isnt much more trudging through the final 15% of bank can doat least from my experience.
Test
UWSA 1

Days Out
39

UWSA 2

34

NBME 11

28

NBME 12

28

NBME 15
NBME 13

21
17

NBME 16

14

NBME 17

Opinion
Like taking four UW blocks. This exam had some similar questions to the CBSE. Only do
UWSA exams if you have more than four weeks or have run through all UW questions
already. Generally, UWSA exams overestimate by 5-10 points though they recently fixed
their algorithm.
Similar to UWSA 1. Though my composite score was the same, my individual blocks
were polarized in score compared to being somewhat homogenous in UWSA 1. I also
noticed that the weaknesses in UWSA 1 that I attempted to correct were followed by an
inversion; a deficit in subjects I was previously proficient in.
This NBME is the easiest of the six and should not be done unless you have ample time
to take 15, 16 and 17, +13.
Slightly more difficult than NBME 11. This was my worst NBME due to taking it
(relatively) back-to-back after NBME 11. Avoid this if you are short on time.
This NBME starts the difficulty of the last three assessments.
If you have four weeks, use NBME 13 as a baseline and NBME 15-17 as testing exams. I
felt NBME 13 was right on the border of the easier questions on Step 1, and it will
definitely accurately gauge how you have been studying thus far.
This is the most difficult NBME. Your score will probably drop a few points but it will
show you how recent Step 1 questions are asked.
Your Step 1 score will most likely be the average of NBME 16 and 17,+ 5 points. Of note,
the Behavioral Science / Ethics questions were annoyingly weird.

As you go through exams you will start to notice that the NBME like to test you on minutia. Memorizing minutia is the
key to breaking a score above 240. The best way to memorize minutia and thus to do well on USMLE World questions,
UWSA and NBME exams is repeatedly going through First Aid.

Reviewing Material:
Anyone can sit and take ten blocks of questions in a day. It takes considerably more effort to go through those blocks
and really understand the explanations USMLE World gives. Initially it took me 30 minutes to do a block followed by 1.5
hours to review that block. The more I reviewed, the more I began to understand and integrate the answers and my
block percentages would go up and I would feel more confident in my answers. As time went on, completing and
reviewing a block would take me a combined hour flat. Create a notebook (or word document) of your mistakes, points
of interest and learning objectives. Review these notes at short intervals periodically. Before you take an NBME, you
should have covered the material youve covered at least three or four times, definitely before Step 1.
A friend in New York sent me several Step 1 note compilations and flashcard decks created by others for a program
called Anki. I always retained material better when I made my own notes, but the decks passed on to me were amazing.
I used a USMLE World deck, a Pathoma deck, and a general Step 1 deck at 15 new/30 review per daythough near my
test days I would push through as many cards. I believe someone also made a deck of First Aids rapid review section as
well as a copy of USMLE-Rxs flashfacts, which will prove invaluable to memorizing First Aid during MS2.

Question Banks:
There is no debate that USMLE World is the ultimate question bank for Step 1 preparation. It features questions
addressing both overlying principles and in-depth knowledge. One of my stronger views regarding Step 1 preparation:

UNDER NO CIRCUMSTANCES SHOULD USMLE WORLD BE USED OUTSIDE OF THE PERI-STEP 1 STUDY PERIOD. Do not
use it starting in August with your regular courses, do not use it starting January, do not use it until after Spring Break.
You will not only remember the questions asked but your understanding will be heavily biased based on what you are
currently studying. Think about it: you will know the details of Lofflers endocarditis in September, but will you
remember them in April? Using USMLE World to study for block exams will result in an inflated percentage and
remembered question stem resulting in your most valuable resource becoming worthless.
Rather than use USMLE World during the school year, use Kaplan and/or USMLE-Rx instead. USMLE-Rx is the question
bank of First Aid, but make no mistakea good 20% of the medium/hard questions are not from First Aid at all. Kaplans
questions are more difficult and feature more recall/integration. I inherited Kaplans question bank in PDF format by
subject so I could not randomize it like I did with Rx or UW; in this fashion Kaplan made for good subject review. My
rationale was doing USMLE-Rx after Kaplan would be best in memorizing First Aid before the CBSE and subsequent
dedicated period. If youre going to use both Kaplan and USMLE-Rx, I would do one in systems mode as youre going
through them in school and the other in timed random mode as you draw closer to your dedicated period.
Unfortunately I started Kaplan after my second pass of First Aid though I wish I had started it with the first block. If you
are going to do just one, Rx might be better closer to your dedicated period. Ideally, finish one bank by New Years, the
other by Spring Break, and then after a review youll be set to do USMLE World during your CBSE/dedicated period.
Unless you are going to be using a question bank for a single subject, blocks should be done in randomized timed mode.
This is to mimic Step 1 but also to make sure you havent forgotten what you learned. Without randomization, your
differential diagnosis will be restricted. A man presenting with chest pain and difficulty breathing in the respiratory
system will elicit a much different diagnosis than similar symptoms in the cardiac module, or even psychiatry
(pneumothorax, MI, panic attack).

First Aid:
About 90% of USMLE World, NBME exams and Step 1 can be found somewhere in First Aid. It is an essential resource
that cannot be ignored. Please do not annotate any class material into First Aid. I saw several people doing that during
classes or in the school year and that is a complete waste of space and time. While I normally abhor writing in books, I
did annotate UW notes into the respective sections to streamline reviewing a particular system/section. I think most
students will do three complete passes through First Aid while in their dedicated period, which is about one pass just
over a week. Below is my First Aid pass schedule:
Pass #
1
2
3
4
5
6
7
8
9

Date / Days Out

~ Halloween
~ New Years
Spring Break
31 days out
22 days out
15 days out
10 days out
3 days out
1 day out

Studying 10-20 pages of First Aid every day during the school year is not impossible: the real challenge is in retaining all
that material. Prior to First Aids flashfacts, I painstakingly spent several months making Quizlet sets of the First Aid
chapters while slowly integrating Pathoma and other resources; repeatedly going over these sets helped to consolidate

information into my brain. Making and reviewing the sets helped me more than any other form of Step 1 preparation
during MS2; a close second would be Goljans audio lectures.
If 90% of exam material is found in First Aid and UW, where is the other 10% found? Interestingly enough: class material.
I had multiple questions in USMLE-Rx, Kaplan, NBME exams and Step 1 that I was able to answer (or at least recognized)
based on class material that was not found in First Aid. Though it seems contradictory since in the last paragraph I said
the majority of class material was not worth annotating into First Aid, I stand by this statement: the questions I
recognized had answers that could be reasoned (to some degree).This is probably done to stratify upper scores. It is
surprising but once again reinforces that doing well in school will help you the most in doing well on Step 1.

Annotating First Aid:

Incorporating notes into First Aid can be a bit of a harrowing experience since UW is a full textbook by itself (if not
multiple textbooks). I came across some pictures of people overly-annotating First Aid to the point where it was
unfathomable as to how a person could realistically study from the book (see below). First Aid has a lot of information
crammed into a small amount of space so avoid filling it with too much minutia. I first incorporated any learning
objectives from UW that were not overtly present in First Aid, secondly from anything I didnt understand in the detailed
question explanation. It is hard to put into words the feeling I got when I came across a small fact that I knew could
potentially be asked, but you will understand what I am talking about when you are going through the question bank. If
you dont want to directly write paragraphs into First Aid, what I suggest is creating a Word document with numbered
bullet points and simply writing the bullet number into that sections margin.

DONT DO THIS.

WHY?

POINTLESS UNDERLINING AND COLORING.

UNNECESSARY.

EXCESSIVE.

Timing/Question Approach:
I never struggled with timing on any exam, usually ending with 10+ minutes in each section to spare. Most people will go
through the questions once, taking time to read the question and answer it, double back to any marked questions then
move on. I preferred to take the shotgun approach: skim a question and select whatever option seemed to be the most
correct within the first 15 seconds, then re-do the entire block in-depth with the time remaining. My logic was as such:
with the first approach, even with the time you spent on a question you could still get it wrong, and if you ran out of
time for the block you automatically got any questions missed wrong. With the second approach, you at least had a shot
to get the question right. Additionally, revisiting each question changes your focus so it can be approached from a
different perspective. You can see from the amount of UW questions I changed from incorrect to correct that this
strategy paid off. You have just about 1.25 minutes per question when the majority can be answered within a minute.
Initially each Rx and UW block took about 35-40 minutes; near the end of each bank I was hitting 30 minutes per block
flat. Similarly for NBME exams: I would take approximately 45 minutes for a 50 question block. For Step 1 I started at
8:30 AM and walked out at 2:00 PM, so roughly 5 hours for the exam with three 10-minute breaks (3/2/1). To do some
unnecessary math: NBME 15, 16 and 17 took 3 hours to do 200 questions (~67 questions/hour or 54 seconds/question);
Step 1 took 5 hours to do 308 questions (~62 questions/hour or 58 seconds/question), meaning I actually took longer to
answer Step 1 questions than NBME questions though it felt like I was rushing. I dont think I would have scored any
better if I took longer on each question.

USMLE World:
Almost everyone will complete USMLE World at least once. Most Step 1 forums claim that the value in UW comes from
the explanations rather than the multiple choice questions. While I do agree that the explanations of UW are amazing,
the multiple choice questions should not be ranked second to explanations. The intricacy and integration of questions
are unmatched by any other resource and should not be marginalized. I treated UW as more of a testing application
than a learning resource since most UW explanations can be found (to a lesser degree) in First Aid.
Most Step 1 forums also recommend not obsessing over UW percentages. There are many reasons for this, one of which
I realized while talking to classmates who were using UW in subjects mode. Obviously percentages from students
studying a system during class would be higher than students in their dedicated period using the bank in a randomized
fashion! Percentages are therefore skewed and should be taken with a grain of salt. I agree with not obsessing over
percentage when initially starting out the question bank, but as you move closer to your test date and are zipping
through blocks (hopefully in a randomized timed fashion) start using percentages as a marker of how you are able to
handle the entirety of testable material. Most websites list 70% and above on UW blocks as great and based on the
NBME percentage-to-score correlation this is correct but this is looking at the percentage as a total, not the last 30 or
so blocks where you have probably hit your stride. In closing, do not worry about UW percentages until youre nearing
your test date, then consider it as gauge of how much you have actually retained. Do not try to correlate your UW
overall percentage to a Step 1 score use official NBME exams instead. If for whatever reason you do want a
correlation, here is the link. Based on the NBME scores being almost 20 points off you should not place confidence in
this analysis.
The most value from USMLE World comes from the first pass. Subsequent exposures invoke memorization of answers
rather than logic. I completed a first pass with an 87% and was debating on re-doing my marked and incorrects (defined
as a 1.5x pass) or just resetting the bank completely (defined as a 2x pass). I chose to do a 1.5x first and was stunned at
my performance. Since I had been reviewing my blocks every couple of days, I did not even need to read half of the
question before I jumped to the correct answer. After three blocks of >95% it was a complete waste of time since I
clearly just memorized the answers so I stopped and focused on doing more NBME exams and reviewing blocks.

I will include this short paragraph on how I feel it is best to answer UW questions. In your first pass, hone in to the
correct answer. This will indicate that you can wade through convoluted questions to find out what the examiner is
asking forand that you know your material cold. In subsequent passes, use the process of elimination method. This
will indicate if you know linked subjects and why that answer choice is not correct in the question scenario.
Overall, there is no real value in completing more than one pass of UW especially if you have been reviewing previous
blocks. If you are fixated on doing multiple passes, these passes should be approached with the intent to remove
incorrect answer choices thus leaving the best possible answer.
My biggest problem answering questions (as those I was in communication with during my study period will confirm) is
that I just didnt read the questions properlyor worse, I accidentally clicked a wrong answer choice. It was the bane of
my exam review seeing a score drop due to selecting pancreas instead of prostate or pyridostigmine instead of
pralidoxime; or other stupid mistakes by not reading the question prompt correctly or zooming through the answer
choices.

Boredom/Burnout:
I hit my first peak around Block 10 as I finished USMLE-Rx. As you can see from my schedule I had several more burnout
daysmainly after NBME exams. I majorly burned out two days before NBME 16, and lastly just before Step 1. If you are
experiencing burnout, take at least half the day off and relax. Forcing yourself to study while burned out is harmful.
Other than burnouts, throughout my study period I was justbored. My baseline was excellent and all my practice
exams predicted I would receive above a 240. I should have taken my exam a few weeks earlier and enjoyed a longer
vacation. This de-motivation significantly contributed to my burnout. If you are in a similar position, move your date up!

USMLE World vs. NBME Questions:

There is one major difference in USMLE World and NBME questions: one big fat fing juicy detail, as a colleague from
VCU eloquently described. Compared to UW questions, NBME are intentionally vague. The NBME likes to ask two types
of questions: either broad concepts like most important risk factor/most common cause of a disease state or a recall
question, whereas UW gives you a question with a definite answer based on keywords or key phrases in the prompt. The
key to doing well on NBME exams is to choose the single best answer based on the case, not always what is correct.

Step 1:
The first thing you will notice is that the actual testing format of Step 1 is nothing like the shelfs or self-assessments
youve taken, its exactly like USMLE World and the Free 150 software format. I dont know if anyone actually utilizes
anything other than highlighting, the calculator and lab values so its not a huge difference. The second thing you will
notice going through the tutorial is that heart sounds can be listened to in four different places and two different modes.
Take the 10 seconds during the tutorial to make sure your headphones work. Other than that, skip through the tutorial
and answer 7 blocks of 44 questions where its business as usual.
Theres some debate as to whether question stems are longer in Step 1 compared to NBME exams. My Step 1 exam
featured some questions with a long paragraph that took me a minute just to read while others were simple sentences
that took me ten seconds to read. Font sizes seemed bigger on Step 1 so that could be the cause of length discrepancy.
There were also definitely some questions with scrolling due to lab values (expanded on below) along with histology, XR,
CT images. Unlike shelfs, everyones Step 1 exam is different.

Much to my dismay my exam was extremely anatomy and biostatistics heavy. This meant that a fair amount of my exam
was recall instead of analytical. Anatomy totaled approximately 4 questions per block and biostatistics approximately 3
questions per block, the rest were varied. Interestingly enough, about half of my biostatistics questions were text-based
definitions, study types, etc. I was stunned when I came across biostatistics questions that were not in First Aid but
were covered in Public Health; similarly with Psychiatry questions covered in BS&P. Anatomy questions were similar to
UW and NBME exams. Biochemistry questions were simplistic like on the CBSE/NBME exams when compared to those
from question banks. Every now and then there was a question on nutrition or quality control which no resource can
prepare you for except common sense. A good amount of questions I came across had some sort of graph or image and
a table for further information with answer choices that depended on the integration of the image/graph and table.
Less frequently there were some questions that were saturated with lab values. I distinctly remember a question prompt
that was one sentence followed by a plethora of lab values, then a follow up sentence with another table of lab values. I
was familiar with BMP, CBC, ABG/VBG and some miscellaneous lab values from pharmacy school but it was clear that I
would have wasted a lot of time if I didnt. Memorizing the fishbone layout and values on the left will help reduce time
looking up lab values pertaining to hematology, acid/base, electrolyte and other disorders.

As for the style of question asked: youve all seen the image on the right; after taking all these practice exams you know
this is not true. Most of the questions end up at the complicated step and only a few go further. Ive always found
NBME questions to be more difficult than UW questions though everyone I spoke to thinks otherwise. Nothing changed
on Step 1: I found Step 1 questions to be significantly more difficult than UW exams/questions and slightly more difficult
than the NBME self-assessments questions I took, especially NBME 16 and 17.

I would usually play through a few songs in my head mentally while taking school exams. The type of music I listen to is
very fast-paced which could contribute to how rapidly I finish exams, and actually my overall demeanorpeople say I
walk fast, talk fast, but I tell them its normal New York speed! Theyre the slow onesanyway, just a funny anecdote: in
the first half of Step 1 things were going well until all of a sudden for some reason, I got Michael Jackson stuck in my
head. The entire last half of my exam consisted of Beat It, Thriller, and Smooth Criminal. I havent listened to Michael
Jackson since I was in elementary school, so I have no idea why these songs became stuck in my head, but they were!
Heart sounds were peculiar on my exam. Without the case, I would have no idea what I was hearing. The cases made the
heart sounds almost useless as anyone who has adequately prepared could answer the questions without even pressing
play. I only had three or four which were hopefully easy points.
In closing, I have shown you my schedule, the resources I have used, all approaches I took, and scores with progression.
There is not much else for me to offer. Good luck and I hope you get the score you want. With the exam out of the way,
enjoy your vacation! You are now officially MS3s so be proud of yourselves for making it this far.

-- I originally wrote this for the incoming MS2s in my class. I dont know if any of them will use it, but I hope you have
found this writeup useful.