USMLE Step 1 score 276/99

I just Received my score on 1/21/2009.

Initial goal: 250+
Total prep time: 1000 hours.

IMG at an Australian medical school (UQ); MCAT=38
NBME 1: 258 (9 months out)
NBME 2: 261 (2 months out)
NBME 6: 262 (25 days out)
UW 1: 265+ (15 days out)
NBME 3: 265+ (8 days out)
NBME 4: 265+ (6 days out)
UW 2: 265+ (4 days out)
NBME 5: 265+ (2 days out)
USMLE CD: 96% (1 day out)

I did over 10000 USMLE-style practice exam questions in the following order:
USMLERx: 94%
Kaplan Qbank: 91%
First Aid Q&A step 1: 93%
UW: 88% (Random, unused, first time through)
Plus NBME + UW exams + USMLE CD + RR Goljan…

Prep material:
FA of course!! I read it cover-to-cover 3 times. However, I tend to cross-reference it when I read other books and I frequently consulted it during second year during PBL. I also annotated notes in FA when I did UW, so I was very familar with the content of this book. For every diagram/table/metabolic pathway in FA, I made sure that they were familiar to the point that I was able to to reproduce them from memory.
Anatomy: Kaplan notes & Kaplan webprep, USMLE Road Map Anatomy, HY Neuroanatomy.
Behavioural science: Kaplan notes & Kaplan webprep.
Biochemistry: Kaplan notes & Kaplan webprep.
Cell biology: HY Cell and molecular biology.
Microbiology: Kaplan notes & Kaplan webprep, Micro Made Ridiculously Simple, MicroCards.
Immunology: Kaplan notes & FA.
Pharmacology: Kaplan notes & Kaplan webprep, HY Pharm, Pharmacology Flash Cards (Brenner).
Physiology: Kaplan notes, BRS Physiology.
Pathology: BRS Pathology, Goljan audio, Goljan notes.

Preparation timeline:
Probably quite atypical compared to most US medical students. I initially intended to sit the exam at the beginning of third year, so I spent a month studying after second year was over. At the end of the month, I didn’t feel quite ready and decided to postpone my exam till the end of third year, thinking that I would have plenty of time to study during the clinical rotations. Wrong. I only had some time during my rural rotation and psychiatry rotation to study for USMLE, but could only manage to do 1-2hr/day on weekdays and up to 8hr/day on weekends. At the end of third year, I spent a month studying hardcore again, and finally took the exam on the 26th of December. The Australian school year runs from January to November, by the way.

During second year – Read BRS Pathology and pretty much memorized the book. I love pathology so it wasn’t really a daunting task for me. I also started listening to Goljan audios in first year and I was really glad that I started early. I finished Goljan audios at least three times, but I always felt that I learned something new each time.

December 2007 – Finished reading Kaplan notes (all subjects except Path) and Goljan notes for Path. 8-10hr/day. (300hr)

Jan – Nov 2008 – On and off. I did NBME1 in March and got 258(720) and was pretty happy that reading Kaplan notes paid off. However, I had only about 4 months during this time (rural and psych) where I could fit USMLE studying into my schedule, but could only manage to study about 25 hours a week. During this time, I read the supplementary material (HY, Road Map, flash cards), listened to Kaplan webprep while commuting, and did the majority of the practice questions. (400hr)

December 2008 – Did most of the NBMEs and UW assessment exams in this month. Completed UW question bank for the second time. Spent the last week just memorizing FA and doing practice questions. 8-10hr/day. (300hr)

Exam on 2008/12/26:

I started the exam at 8:30 and finished at 4:00 with 20 minutes of break time to spare. On average, I spent 45 minutes in each block and took a 20-minute break after each block (except the first block). During each break, I would drink 300mL of oolong tea or green tea to keep me awake, eat half a sandwich, go to the washroom, and wash my face so I felt refreshed and ready to tackle the next block. I thought the strategy worked quite well for me.

I thought the exam was quite a bit harder than NBME but easier than UW. It was probably comparable to UW self-assessment exams in terms of difficulty. I marked 6-7 questions each block. I thought 85% of the questions was straight-forward, 10% was tricky, and 5% was difficult.

Pathology: Not surprisingly the bulk of the exam. Around 70% of the questions were patholgy questions or required pathology integration. I thought UW covered these sorts of questions really well, so there weren’t really any surprises for me. I only had around 5 questions that came with pictures of gross pathology specimens.

Anatomy/neuroanatomy: 15 questions. Most of them involved intepretation of X-rays/CT/MRIs, nothing too obscure. I even had brain CT and angiograms for structure identification. Make sure you know the brain stem and cranial nerves well.

Behavioral science: 20 questions. Half were biostatistics, and the other half were the typical “what would be the best action/response in this scenario” type of questions. I thought just reading FA or Kaplan notes was not really sufficient to answer these sorts of questions. I had almost no questions that came out of the psychiatry section in FA, except a few psychotropic medications and a question on defense mechanisms.

Biochemistry/Cell bio/Molecular bio: Geez, I noticed the trend of increasing proportions of cell biology questions in the NBME, but I never expected this many on my exam. I probably had 50 questions that fell into this category (Biochem/Cell bio). I was glad that I flipped through HY Cell and Molecular biology just a few days before the exam, because it probably helped me answer 5 questions correctly. The different kinds of receptors and intracellular signalling pathways are extremely high-yield. For metabolism, know the key regulatory enzymes and global control of metabolic processes (i.e. insulin vs glucagon’s effects).

Pharmacology: Around 25 questions. Piece of cake compared to UW. I thought FA covers pharmacology in sufficient details. As usual, emphasis was placed on autonomic pharmacology and cardiovascular medications. I had quite a few questions on pharmacodynamics too.

Microbiology: 30 questions. Make sure you know the various bacterial exotoxins and their mechanisms of action. Quite a few questions involved TB and HIV. Even West Nile virus appeared on my exam.

Physiology: 30 questions. Most involved the up/down arrows and graph interpretation. Endocrine questions are high-yield too.

I walked out of the testing centre feeling quite confident I did pretty well. I was certain I broke 260, but wasn’t too sure if I was able to get 270+. Got the score last Wedneday, 276/99! I didn’t even know it was possible! Needless to say, I was ecstatic!!

I’ve compiled a Q&A from the emails and PMs I’ve received since last Wednesday. I’d like to thank those who emailed or PMed me and also their permission to post their questions up. I hope this answers more questions regarding my exam preparation.

Learning Resources:

Q: What edition of Kaplan notes did you use, and did you use the accompanying videos?
A: I used Kaplan notes 2004 edition. I was running out of time toward the end of my preparation so I didn’t use the videos.

Q: Did the Kaplan webprep audios make a big difference where the lecture notes are concerned?
A: I wouldn’t say the webprep audios were essential, but they certainly helped solidify many important concepts, especially for biochem and pharm. If time is a factor for your preparation, I would suggest doing the webprep audios only after you finish reading the lecture notes.

Q: First Aid – how much does it cover?
A: FA covered about 80% of the material on my exam, so I would definitely recommend using it as the primary resource the week before the exam. I went over the rapid review section at the end of FA the night before the exam date, and I found it quite helpful as a last-minute review.

Q: Do you think the lecture notes for biochem are okay to use without the videos?
A: I think the lecture notes for biochem are adequate to be used on its own; I didn’t use Kaplan videos so couldn’t comment on them. However, I would highly recommend listening to webprep for biochem. Dr. Raymon is just simply amazing; he does an excellent job integrating pathology, pharm, and biochem. However, it is still of utmost importance to memorize all the tables/diagrams/metabolic pathways in the biochem section of FA. I think it really ties the information together nicely toward the end of the preparation.

Q: For Pharmacology, do you think studying FA is enough?
A: I think FA is enough for Pharm, provided that you know the mechanisms of the drugs well. I found it quite difficult to memorize the list of clinical uses and side effects without having a solid understanding of the mechanisms, so I chose to do Kaplan notes before tackling FA, and it certainly made those things easier to memorize.

Q: Did you like the Pharmacology flash cards you used or were they too detailed?
A: I liked the flash cards, they are handy to carry around if you want to study them on the bus or during a boring lecture. It can also be conveniently used to quiz yourself, with the drug’s generic name and trade name on one side, and the list of drug class, mechanism, clinical uses, side effects, route of metabolism on the other side. I don’t think they are overly detailed.

Q: Despite reading Microbiology Made Ridiculously Simple over again, I am still missing tons of micro questions. I dont feel like there is anyway to “master” these questions cause they often test trivia that while I know I read, I just cant recall on the spot. Although, I do think my main problem here is focusing too much on MRS and not on FA.
A: I agree with you that using FA to supplement MRS would be very helpful. It’s a good idea to start with MRS in the beginning of your preparation, but toward the end, the tables in MRS and the charts in FA are the way to go. A heavy amount of rote memorization is required to master Microbiology, that’s for sure. I would encourage you to focus on the classifications and lab algorithms first before you start memorizing the rest of the minutiae. (Remember: Big pictures first!) The gram positive and negative lab algorithms in FA are gold. Pay close attention to the bacterial exotoxins as well, because they frequently appear on the exam. Make sure you know these like the back of your hand. For virology, use the mnemoics in Kaplan notes to remember the DNA, +RNA, and -RNA viruses.

Q: You mentioned that kaplan and FA were not enough for behavioural and biostat questions. Any suggestion what shall I go for to cover that?
A: A lot of my friends liked HY behavioural and biostats a lot, but I have only read the first few chapters of HY ** so I can’t really comment on them. I didn’t like Kaplan and FA because they focused too much on the psychiatric disorders, and not so much on the “best response/action” scenario type of questions. The practice questions from UW and NBME are very good though, and I would recommend doing as many questions like those as you can, so you’re familiar with the concepts. Sorry to confuse you, but for biostats, I think FA is quite sufficient, but make sure you are comfortable doing those calculations and drawing those 2×2 tables. Doing lots of biostats questions will definitely help solidify the concepts.

Q: How much do you get through a day and how do you retain that information? One of my problems is that I get through maybe 30 pages of Kaplan Biochem notes a day, and at the end of the day, while I retain the information, I find that I really didnt learn that much. Furthermore more, I tend to forget things as I go. When I do questions later on on the same subject, I forgot much of what I learned maybe 2 weeks ago.
A: Don’t worry too much about having to retain everything in Kaplan notes, it’s impossible and often unnecessary to try to remember some of the details. I think the primary purpose of reading Kaplan notes is to help you understand FA later on so you can memorize the facts in FA with better ease. What types of questions are you getting wrong, are they questions that require straight fact-recall or ones that require you to apply a concept? If it’s the former, I wouldn’t worry too much about Kaplan notes and would probably spend more time studying FA instead; for the latter, you do have to make sure you comprehend the info in Kaplan notes before moving on to FA.
Another thing I found helpful was to read the corresponding section in FA after finishing a subject in Kaplan notes. It helps solidify information right away.

Q: How many pages of FA and kaplan notes can you get through in a day?
A: I set goals to get through 100 to 120 pages of Kaplan notes every day, at the speed of 12-15 pages per hour. It depends on the subject too; anatomy and biochem were slower, whereas physiology and pharm were faster because I had done BRS physiology and Pharmacology flash cards already. I could read around 60 – 80 pages of FA in a day toward the end of the preparation, but when I first started, it was painfully slow. I could remember spending an entire day just studying the embryology section, which was only a few pages long but very memory-intensive. But once you start remembering the mnemonics and are familiar with the content, the speed goes up quite quickly.

Question banks:

Q: Did you do questions after each subject during your initial read, or did you skip questions altogether until after you completed your first read?
A: Thanks for raising this point as I probably didn’t make it very clear in my post. I started doing questions after reading all of Kaplan notes, BRS path and phys, Goljan notes, and most HY books that I mentioned. The only book that I was still reading after I started doing questions was FA.

Q: When you say you did 10000 questions, do you include the book questions or any other questions?
A: I only counted the questions in USMLE format.
UW (2000) + Kaplan practice tests (2000) + Kaplan Q-bank (2000) + FA Q&A (1000) + USMLERx (did ~2000) + NBME 1-6 (1200) + UW self-assessment 1&2 (400) + Goljan RR Path questions (100) = 10700
I didn’t count BRS questions or questions in Kaplan notes because they were not always in board format.

Q: Did you do robbins review of path? Was USMLERX useful?
A: I didn’t do Robbins, and I wouldn’t recommend it either. USMLERx was okay in terms of helping me memorize some details that I wouldn’t have paid attention to in FA, because this Q-bank is basically based on the material in FA.

Q: Would you say that a particular question bank or all the 3 question banks that you did do cover all the usmle questions (=subject matter) that you were asked?
A: I would say UW was the most high-yield of them all. USMLERx and Kaplan Q-bank have been known to test minutiae that are not necessarily high-yield info. These 3 question banks combined definitely covered more than any one of them alone. As I mentioned in my post, only 5% of questions on my exam were things I had never encountered before, so doing tons of questions was certainly helpful for me.

Q: I am dedicating a solid 8 hours everyday to question banks (I time myself), but my scores are not improving. What can I do?
A: I would recommend going over the explanations in more detail, making sure you really understand what the question is asking. Don’t skip the explanation for questions you answered correctly; you can learn a lot by reading about why the other choices are wrong. It can take a very long time when you first start doing it this way, but after a while, if you learn from your mistakes, you will not get the same type of question wrong again. When I first started doing questions, it often took me 40 minutes to do 50 questions, but an hour to read the explanations and annotate notes into FA. However, I learned a lot from the explanations in UW, probably just as much as the questions themselves. It’s easy to feel frustrated when you first start, but with time, I’m sure your accuracy rate will improve. Good luck.

Q: I am quite frustrated with questions that test minutia details, e.g. “Which of the following can be found in bacterial endospores?” (Answer is dipicolinic acid) I had never seen anything like that and I had to flip through pubmed to get the answer. Are these questions worth remembering?
A: I’m not trying to discourage you here; although dipicolinic acid is probably a trivia type question, it was actually mentioned twice in FA, so I’d actually still remember it. Sometimes the strategy is to eliminate the other answer choices if you couldn’t recognize the right answer. For example, if other choices are peptidoglycan and mycolic acid, you know they just can’t be right.

Q: What did you annotate into first aid? Only qbank questions? I find some of the Micro Qbank questions extremely tedious and testing pHD like material. How can I tell if its important? Or is it all completely important?
A: I only annotate information that I consider “high-yield”. As you do more questions, you’ll soon know what types of questions tend to show up over and over again; these are the ones that are high-yield.
Take Micro for example, they often give you a clinical presentation of an infectious disease, then ask you for the most appropriate antibiotics. These require a two-step process (Presentation – Bug – Antibiotics), and are guaranteed to be on exam. If they want to be mean, they can ask you about the side effect of the most common antibiotics used. These questions require a three-step process (Presentation – Bug – Antibiotics – Side effects), and are less common than the type of questions above. Things that aid in the laboratory diagnosis or things that have to do with treatment (for example, HIV gene products and antiviral drugs that target these products) are also extremely high-yield. Ignore the weird trivia type of questions that have no clinical correlation.
I agree that Micro Qbank questions can sometimes be a bit annoying, but that doesn’t mean the real exam is like that. I found that FA covers > 90% of the Micro questions on my exam, so make sure you know FA well and don’t get too discouraged by the low-yield questions.

Q: About doing usmleworld 2X: did you find that helpful even though you already did the same questions once?
A: I did UW again one month apart. I don’t think there’s much benefit doing it again right after you finish it first time through, but a month gives you enough time to test if you really understand the materials tested, and not because you memorized the questions and answers. For me, the second time helped me increase my speed as I was more comfortable dealing with long question stems (but that could be an effect of having seen the questions before as well).

Q: When should I do UW again?
A: I would recommend doing UW again as close to the exam date as possible, while still giving yourself enough time to go over FA again and do the rest of the NBME forms. I went through UW the second time 3 weeks before my exam; I did 350 questions every day to simulate the exam length and build up my stamina. When I finished, I still had 2 weeks left to review the material that I mentioned above.

Q: When did you really start feeling comfortable with the material?
A: I probably started feeling comfortable with the material after I finished Kaplan notes and had done 2000+ questions. By that time, I knew my strengths and weaknesses and knew what to focus on in order to get the most out of the review process. For example, after doing some questions, I realized I had a lot of trouble with neuroanatomy, and so did HY neuroanatomy for 2 weeks, which seemed to effectively remedy the problem. Besides, as you do more questions, you soon realize the amount of information that FA actually covers. The questions also help you remember the material in FA more easily.

Q: Any advice on test-taking strategies?
A: One thing I found really useful from doing tons of questions is that on the real exam, I could often read the question stem and predict what type of question they were going to throw at me. I would also recommend coming up with your own answer in your head before you look at the answer choices; reading the other answer choices (distractors) before committing to a response can be confusing, especially when you’re not very certain of your answer to start with. Of course, if you really have no idea what the question is getting at, reading the options first while using the process of elimination is often helpful.