My Step 1 Experience in Final Year MBBS: Mohammad Hamza (Class of 2016)

I am writing my Step 1 experience for undergrad students who find it hard to  manage thier coursework and Step 1 preparation side by side, given our coursework is at a complete 180 degrees from Step 1 preparation.

Basic idea and busting a myth:

People say that step 1 is mostly FA with UW add-on. It is the biggest myth. What works on step 1 is your knowlegde foundation, more conveniently known as "background knowledge". What makes this knowledge is the effort you put in your coursework. In other words you need to be as much serious during your prof exams as you want to be while in your dedicated step 1 preparation. A good knowledge foundation has following benefits:

·         It makes it easier to grasp step 1 concepts.

·         Gives you step 1 knowledge and in dedicated step 1 prep there is nothing new just new ways to test a fact, after a good knowledge foundation you just have to organize it during your dedicated prep and viola you are good to go.

·         Step 1 test not just your knowledge but your mastery of it. How do you get mastery; by working a concept over and over again. Do you really think you can master all concepts of 11 subjects covered by step 1 in just 8-9 months. If you can then you are a genius and this post is not addressed to you. For all others like me out there perseverence is the key to success. Moreover, all those that I know of getting 250+ in their exams really did hardwork all through their course years.

·         Gives you an excellent profile in your MSPE portal while filling out ERAS application (those who are currently playing this years match have told me that MSPE was inquired about during their interviews.

How to get a good foundation while preparing for Step 1? Easy.                                                                               

Suppose you are in 3rd of medical school. You have a test of pharma. If you dedicate 3 days for usual test prep; this time you dedicate 6 days. In forst three days you study Kaplans with lectures and annotate them. In the next 3 you study katzung. In this way you get prepare your step 1 pharma and also your coursework. This not only strengthens your coursework but also it makes you learn your step 1 pharma, over time with coursework, drop by drop before you even start your dedicated prep, you are finished with lectures of kaplans. and when you learn kaplan alongwith kaplan in your send-ups, profs, vivas; you get kaplans in your bones before you even start a step 1 prep. And use good standardized books during your medical school. Dont use Mushtaq for biochem - it kills your brain. I know that some HoDs recommend horribly bad books, but I promise you that they wont fail you if you study from Lippincotts.

Your Step 1 prep starts at the time you enter medical school (quote FA). You must utilize your class tests, profs as a tool to strengthen your step 1 prep, like you did with mock exams for MCAT.

Subject strategy:

Anatomy:

Used Kaplan for Neuroanatomy, nothing better that this book. For Gross Anatomy I listened to kaplan lectures plus I used Snell's review for a better understanding. I highly recommend Snell's review. It refreshes your 1st prof memories in a short period plus it has almost all of the clinical case scenarios regarding anatomy that you could be asked in step 1. Here the knowledge you gain in your 1st prof helps immensely. I used Student Grays and Lasts anatomy during those years and I highly recommend this combination. For Histology, don't sweat this, even UW with nothing else can sail you through it. For embryology, I couldn't find any good book on the market, so I resorted to kaplan with lectures and what I did earlier - A combo of Langman and KLM for step 1 (I struck a sparrow with cannon expecting that I would encounter an eagle). High yield was not upto my taste, if you can digest that book then it might be enough too.

Physiology:

Kaplan classroom lectures with new Kaplan book is enough. Doing this there is no need to go through BRS. Apart from these I highly recommend doing as much Physiology and pathophysiology questions as you can. This will make a difference in your exam.

Biochemistry:

Kaplan with lectures does the trick. But you must have gone through Lippincott in your preclinical years as it provides the much needed knowledge base on which you build your step 1 prep. There were a lot of occassions while doing UW when I felt that if I hadn't gone through Lippincott in 1st prof I would have been at a distinct disadvantage.

Pharmacology:

Kaplan lectures by Sir Lionel P Raymon with Kaplan book PLUS mini Katzung. This is the essential combo for both coursework and step 1. I even went through mini Kat while my dedicated Step 1 prep as FA follows Katzung much closely than Kaplan. Nevertheless Sir Raymon provide much needed concepts without which you cannot even dream of learning mini Kat. Moreover you may find that Anthony Trevers is a co-author in both the books. You have to go through this combo at least 5-6 times during your coursework to get a firm grasp on pharma. After you have mastered that, FA alone is sufficient for getting a star in pharma on step 1.

Microbiology:

Kaplan with lectures is enough. Dont sweat on Levinson. I never went through it during my course years. Kaplan does the job. You just have to go through it until it residues in your bones. After mastering this FA alone is sufficient for a star on step 1.

Pathology:

The Biggie. Use Pathoma with lectures. Once you are done with it. Learn the whole chapter, then go through the same topic from FA. Underline information in FA not in pathoma and then transfer that to pathoma. Then go through the same chapter form goljan. Learn pathology at least 10-12 times. I can't stress this anymore. If there is any subject that will decide your fate on step 1 that is pathology. Every question will start form a pathology vignette and then based on your diagnosis it would ask you basic anatomy, physio etc. But they all start with patho. If you are weak in this subject you are going to perform poorly on all others as well.

People say goljan is not necessary now a days since pathoma does a very nice job. I partially agree. But understand this - Goljan not only teaches you pathology, it also integrates pathology with anatomy, pharma, physio, biochem. This integration is not found to that extent in pathoma. So goljan trains your mind to jump from one discipline to another which is the name of the game. So if you ask me, Goljan is a must and so is pathoma. This is a killer combo for step 1.

Once I transferred all relevent data from FA to pathoma. I never went through those pages form FA again. I even wrote UW points on pathoma. so pathoma was my ultimate book in the final days of step 1 prep. It gives you the advantage of having a good page memory form a single source and avoids you the hassle of opening FA and pathoma side by side and saves a lot of your time.

Genetics:

You have to go through kaplan with its lectures for basic concepts (since genetics is not taught in our school; they teach us molecular biology in the name of genetics!) and after that FA with UW.

Biostatistics:

Kaplan lectures for baseic concepts and then you must go through high yield biostats at least twice for grasping major concepts. Kaplan alone is insufficient but it is vital. Then do UW and UW biostats review; both are essential. No need to go through this portion form FA at all it is ghastly inadequate and often times questions like forest plot are asked in step 1 that is only mentioned in UW biostats review and High yield, nowhere else.

Ethics:

This was the most difficult subject I encountered during my step 1 prep. I used Conrad Fisher cases, Khan's cases, BRS Behavioural Science Mcqs, UW, Kaplan Qbank, USMLE Rx. But in spite of all that I couldnot improve my score on exam. It stayed the same on my NBMEs and my exam. Do whats best for you here. But Conrad's cases, UW and BRS Behavioural science Mcqs are a must.

Immunology:

Kaplan plus lectures do the trick, no need for Levinson even in coursework. Even during dedicated prep you need Kaplan time to time.

First Aid:

It is an important source but a dry one. What matters is how much you irrigate it and that depends upon your knowledge foundation. A good knowledge foundation and FA will work wonders for you. A poor knowledge foundation and you will get bogged down by the tiny details in FA and you will end up cramming it again and again. I have seen people spending more than 2 years studying Step 1. They take so much time because by the time they get to end of FA they have forgotten earlier points. And they start all over again and the cycle goes on. This is a book containing random facts and no concepts at all, you cannot rely solely on FA for step 1 prep.

Uworld:

If anything that makes you exam ready that is Uworld. Do this ONLINE. Your success on UW is directly linked to your knowledge foundation. If you have a good knowledge foundation then doing UW once is enough and you will get through it with an average above 85%. How many times you must do it, it depends upon how much you are ready for exam. I did it once only and found that sufficient. My friends did it twice. What is important that you take your time with it. Don't rush it, digest it slowly and integrate it with your previous knowledge.

The way I recommend is this:

·         Buy 6 months online version with UWSAs.

·         Do subject wise. This makes your mind jump form one system to another and prepares you better for the real exam.

·         Do only one block per day. Take 10-12 min for a question and jot important points down. It will take upto 6-8 hrs. After that go through what you have written and lastly revise a bit of that subject from FA or pathoma (for pahto).

·         Do this regularly every day. a 60 block UW take 2-2.5 months and prepares you for the exam and also helps you assimilate that knowledge. Moreover at the end of this period not only you have gone through the enitre UW but also you have revised your FA once.

Timeline:

Prep start: start of 3rd year.

Dedicated prep: 8 months.

NBME scores:

NBME 7 offline - 29 may - after course revision without UW - 254.

NBME 11 offline 25 july - after UW - 257.

UWSA 1 online - 264.

NBME 15 online 6 sept - after going through entire coursework again - 256.

UWSA -2 online - 269.

NBME 12 offline 15 sept - 261.

NBME 13 online - 256.

NBME 17 online - 262.

NBME 16 online - 258.

NBME 18 online - 2 days before exam - 262.

Real deal - 5 oct - 261.

Dedicated Prep time:

I booked a place a reading room. That place is the holiest of the holies for those who are doing step 1. I divided a 15 day time for each subject (more than sufficient even a little extravagant). I did Kaplan once more learnt it again and then did that subject form FA. I made short notes of Kaplan in those days. In those notes what was written in kaplan in 4 pages, I narrowed down the crux into 1 page and stapled that page in my FA. So everytime I would open FA i would get a glimpse of Kaplan.

It took me 4 months to finish the whole course. I did a bit add-ons linke Snell's review twice, annotated important Goljan points on pathoma (by the end of my prep , my pathoma was all hefty with lectures, FA, UW and goljan) and did Conrad's and Khan's cases alonng with BRS BS. I jotted down their important points on a seperate page. You are right! by the end of my prep, i made short notes for all the subjects of step 1 - my own quick review series. I went through my notes 2 weeks prior to exam and that helped me a lot.

After 4 months I took an NBME-7 and I got 254. I knew that moment that I was right on track but since I had not done my UW I did not take my triad. I did that after 2 months at the end of July when I completed my Uworld and took NMBE -11. After UW I had to attend maternity duties in LWH. That took its toll on me I had to juggle my time to find even a single moment to study while attending LWH. What I could have done in 1 week, I took 2 weeks. Nevertheless, Maternity ended and taking 1 week more I finished my revision and took NBME 15 online getting 256. At that moment I took my exam date exactly after a month.

In the next month I isolated myself from all the hassle of classes and attendence. I carved out my own little corner in a far away land and studied like a ninja. I had my clock wired 15 min for lunch, 10 min for each prayer. Dont drink too much water to minimize bathroom breaks etc. IN the last week I went through those topics that I find somewhat cram-worthy - topics that would only remain in your memory for a short time and then fade away like growth development table or storage diseases etc.

By the end of that period I started having sleepless nights from anxiety. Thats where Zolpidem comes in handy. It gives you a good 6 hr sleep without affecting cognitive function. I recommend that if you are anxiety freaks like me try taking this medicine 10mg at least 10 days before exam to see if it suits you and get acclimatized with it. You dont want to try anything new on the night before the exam. Exam day is not a day for drug induced/withdrawl headaches or the night before insomnia.

Exam Day:

Possibly the best day of my life! I have given many exams before, but this exam was like no other. Prof exams make you wake up all night for preparation, but this exam is not about what you have studied the day before rather what you have studied throughoit your med school career.

·         Important points for attending a prometric centre:

·         Take your permit, CNIC, Passport and Appointment confirmation with you.

·         Wear loose easy clothing, for boys wear sleveless.

·         Take some light snacks with you. I took sandwiches which I couldnot eat. Rather I took milo tin packs. they give you quick energy (if you are not into energy drinks) and much needed glucose for proper brain functioning! Take some medicines with you. I have allergic rhinitis so I took Fexet D with me. Also medicine for headaches if you get them often - I took Panadol extra for that purpose. Take anti-diarrheals and diphenhydramine if you get GI problems during exam.

·         Time your breaks. I took a 10 break every 2 blocks. Second break was larger, I said my prayers in it. Believe me there is no anxiety buster better than saying a prayer during exam.

I found questions were mixed on the exam. Some dead giveaways, others would make you think, others still you can guess bu eliminatng all the wrong choices and remaining ones - you will not get even if you are a professor of medicine. The right strategy is read the last statement and then look at the stem to find relevent information, choose your answer and move on. If you are unsatisfied amrk it and move on. Do not think on it too much. After you are done with all the questions, you will find time to return to marked questions and then you can cringe all you want. Using this strategy I was able to finish every block 10 min ahead of time (one block 20 min ahead of time). Then i would go through all my marked questions and change any answer that I deemed fit. At the end of every block I was sure that I did every block to the best of my knowledge.

Important thing: This is not a 45 min mcq exam like we face in profs. This is an 8 hr exam. You can get through short term cortical memory in profs but not here. After 2 hrs cortical memory begins to fatigue and you then rely solely on your reflex memory. So, key to scoring well is having a good reflex memory. eg when you see a pt with a worsening renal function in adulthood you must reflexly think of ADPKD and by extension cerebral aneurysms. A strong reflex memory minimizes your preventable mistakes which you make due to mental fatigue and also decreases the stress on your cortical memory and makes it less fatigueable. How to make a strong reflex memory - Do well in your med school coursework (I cant stress this enough!).

Using the above strategy I was well contented with my exam which i finished with 20 min remaining in my break time.

Lastly and most importantly:

This is an exam of nerves. You need to keep calm and reassure yourself that you can do it. Stay away from CRAP which stands for Criticism (negative one), Rejection, Assholes and Pressure. Many people would want you to not do it and they will sway you from your goal by either saying you can't do it while an undergrad, it's too difficult or its easy you can do it later. These are exaclty the A of CRAP I'm talking about. Have faith in yourself and do ask for Almighty's help. Keep a circle of close friends who are pursuing similar goals. They will help you keep on track and are the best anxiety busters. I cannot thank my friends Raza, Farhan, Sheikhoo and Fraz enough for that.