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Oh Boy, the all anticipated boards, I remember when I was preparing for this exam, my brothers told me that this would be the most important exam of my life, which of course stressed me out tremendously.  My advice, after talking to many program directors, is that yes indeed they are very important.  My other advice is that you can do as well on this exam as you prepare.  First, when it comes to preparation, you must know by this time what works best for you.  Do you work best studying in a group, or by yourself.  At school in the library or at home.  Do you need a structured preparation course, or can you do well with a review book.  Also, think back to what worked for you on the MCAT because you probably did quite well if you got into medical school.  And in fact,when going into this exam keep that in mind.  Even if you did average during your first two years of medical school, you are still exceptional for even being in medical school, and quite capable of doing as well as you like.

All about Step I

The step 1 of your boards, test you on all information learned in Years 1 & 2 of Medical School, considered the Medical Basic Sciences.  What you learn during years 3 & 4 are considered the clinical sciences.  Medical school is grueling, and there is so much to learn on a day by day, month by month basis.  So imagine reviewing all of that into preparing for a one day test.  It’s tough.  The importance of your score in the exam depends on what type of residency you wish to pursue after medical school, and where.  It may be difficult to know for sure at this point what specialty you wish to pursue, but doing well on step one will keep all doors open, and doing poorly, will close many.  Despite the intended principle of this exam to only measure basic science knowledge for the purpose of medical licensure, many residency programs use your score on this exam, like some medical schools use the MCAT.  That is, to set a cut-off score and only review applications from applicants whose scores measure above.  That being said, you can expect that doing poorly or even average, can limit ANY residency position at the BEST hospitals.  Furthermore, certain specialties are so competitive, that regardless of where you apply, your scores are crucial to getting in anywhere (i.e. Neurosurgery, Orthopedics, Plastics, Radiology, Dermatology, ENT, etc).  Last but not least, programs in cities like NY, or LA tend to be highly desired, and are often more competitive than other “less desirable” locations.

First Strategy

Don’t be afraid.  Like I said before, I was told that this would be the most important test of my life by my older brothers, and I was freaking out in the weeks prior to the exam.  Although this test is extremely important primarily for licensure, but secondarily for getting into residency, you must always remember to keep your cool, and know that there exist strategies to help you do as well as you would like (or close too it).  Keep in mind that everyone in medical school including yourself is exceptional.  If you have already forgotten, talk to some current pre-med undergrads about remember how hard it is to get into medical school.  Therefore, remember that you are still exceptional, and regardless of your first two year grades, you can still do well on the boards (it just might take a little more work, that’s all).

Topics from 1st and 2nd years covered include: anatomy, behavioral sciences, biochemistry, microbiology, pathology, pharmacology, and physiology, as well as interdisciplinary areas including genetics, aging, immunology, nutrition, and molecular and cell biology.  Physiology encompasses cardio, renal, gastro intestinal, etc.  This exam, focusing on individual organ systems is further subdivided according to normal and abnormal processes, principles of therapy, and psychosocial, cultural, and environmental considerations.

Once upon a time, the test was administered over two days, in written format, and administered on specific dates.  With the advent of computers, things are quite different.  The exam now is scheduled at testing centers across the nation (and world), taken completely on computer.  Once completed, the exams are graded electronically, and you receive your results nearly 6 weeks after.  The exam is subdivided into seven, 50 question blocks for a total of 350 questions, timed at 60 minutes per block.  The exam begins with a 15 minute tutorial that if you complete before hand, the additional time will be forwarded to your allotted break time.  At the end of the exam, there is a short questionnaire block, that does not count towards your final score.  Once you begin a block, the 60 minute timer will not stop.  Within in each block you can review questions and change answers.  However, once your 60 minutes are up, or once you have decided to finish a block and move to the next one, you can not return to previous blocks to make changes.  The advantage to finishing a block early is that the extra time is forwarded to your allotted break time.  IMPORTANT:  finishing early does not provide extra time towards future blocks, all blocks are at most 60 minutes long, time is only added to your breaks, and rushing through the exam for this slight benefit is not advised. 

Registering for the exam-To register, you must designate a 3 month period in which you wish to take your exam.  Once you are approved for that 3 month period, you can call the Prometric testing center, or schedule online a specific date within those three months, depending upon availability at specific locations.  (Some locations offer weekend test dates)  You can choose from any national Prometric testing location.  The fee for the 2005 test is $445.  The fee for extending your 3 month testing period by another 3 months is $50, and it can only be extended once.  Additional extension will require re-application, and re-submission of total fees (yup, another $445).  You can complete the application partially online with a portion to mail in, or download all forms to complete and send in with a check.  Go to www.nbme.org to find out more about the online, and downloadable applications.

Preparing-So how do you prepare.  Most students take the exam the summer immediately following their 2nd year, in the few weeks available prior to starting their 3rd year.  It is very important that on the onset, you evaluate your goals, and formulate a plan/time-line that is realistic and that you can stick to.  4 weeks is the average length of time.  Probably the best way to prepare for this exam is by doing well during your 1st and 2nd years.  For those who did very well, perhaps 3 weeks will suffice depending on your goals.  For those who did not do as well during the 1st two years, you may need a little extra time, but not too much as it is very easy to get burned out.  You will be better off with a more thought out, and dedicated study plan.  I would say that an absolute limit for all students would be six weeks, although if you plan well, get good books, and do lots of questions, 4 weeks will still be good enough.  Make sure when making this plan, you research what resources your school may offer to help guide you.  Some schools have test specialist, who can help you develop this plan based on your goals, and recommend (or even lend you) books and materials to study from.

Q-bankTM, First AidTM, Step-upTM, and other resources

Kaplan offers a preparation course for about a thousand dollars.  They also offer Q-bank online for about $179 for one month, and $279 for 3 months.  Everyone talks about Q-bank for the boards, and it is indeed a great resource (however, fees have considerably increased over the last 2 years).  It essentially is a bank of questions, administered in the same format as the real boards, on a PC over the web.  The tests are timed, and the interface for the test is pretty much identical to the real boards.  They offer about 2500 questions, and you can set up your test by specific topics, or organ systems, to work on specific weak areas if need be.  It also keeps track of your performance, and gives you feedback based on topics and organ systems so you can adjust your studying accordingly.  I used to think that everyone should use this resource, however probably only those who can afford it.

Another key point is to keep in mind the common pit fall among students.  Many people tend to review topics they are already good at, and over look those they are weak in.  Most of the time it is because it can be more frustrating.  However, some of the greatest advances in score come from identifying and then working extra hard in these weaker areas.  Remember that.

Your scores on Qbank are broken down by discipline, for instance anatomy, behavioral sciences, biochemistry, microbiology, pathology, pharmacology, and more, and tells you in which discipline are you proficient or deficient. Besides breaking it down into disciplines, it also breaks it down by organ system, reporting proficiency and deficiency. You can later create test with emphasis on these specific disciplines or organ systems as mentioned before. The big question about Qbank, and you will find much debate on this, is how much the questions on Qbank resemble the actual test questions (a sample scale can be found below)? You will hear lots of opinions, but in mine, the average Qbank question focuses on more detail, than the average question on the actual exam. This is an important point, because the majority of the questions in Step 1 focus on less detail, and cover the major more fundamental concepts of medicine. Qbank questions focus on more detail, of more extraneous/non-fundamental topics in addition to fundamentals. Making sure you have the fundamental concepts to medicine down is essential, as the majority of the questions you will encounter on the real exam will be aimed here. However, mastery of these fundamental questions in great detail, AND the more superfluous ones, is what will help you answer these rarer types of questions, and set you above the average score into exceptional. The reason I stress this is because I feel that when I was studying for my test, using mostly Qbank questions based on its popularity, I was steered under the impression that most questions where going to be at that level of detail.  I focused on these details, loosing sight of the central more fundamental concepts of medicine which also required mastery. During the actual exam, I found myself cruising through these superfluous questions, and under-pressure through the more fundamental ones, and there are a lot more fundamental questions. A good contrast between fundamental and non-fundamental can be made when looking at the kidney, and details on how all its segments work for example, versus all of the possible manifestations of Von Hippel Lindau Disease. Ultimately, the exam went really well as apparent by my score, but I probably missed a couple of more basic, fundamental questions because I overemphasized on the rarer more detailed ones. Had I known this before, I could have probably done better.

Sample questions are also available by NMS in “Review for USMLE Step 1; 6th Edition”, and these are also known to be pretty good. Ask around, and see if you can get sample test from some third years, in addition to more advice.

Currently the two most popular review books for Step 1 are First Aid for Step 1, and Step-Up.  First Aid goes by disciplines (such as biochemistry, pathology, microbiology, pharmacology, etc), Step-up goes by Organ systems (Heart, Renal, GI, endocrine, etc).  For Step 1, they are useful to review topics as high-yield quick reads and as a supplement to your primary reading, but probably not sufficient as a single source to do very well on the exam.  In my preparation for the boards I used both books during year 2 so that I could review them for the test.  I thought studying for the boards using these two different approaches worked well (I also dedicated about 50% of my time to Q-bank, and read an out of print Princeton review book on the boards before even getting started).  First Aid has a great pathology section with spectacular images, and review lists for high yield studying.  Step-up really helped me throughout year two, when my courses were all organ based, correlating with highlighted topics I should reinforce in preparation for the boards months later.  You can usually pick up a used copy of the book from a previous year.  I don’t advise using any review books that are 2 years out of print however, because information there can become outdated fast (First Aid I believe updates their books every year)

Self Preparation or Review Course

This is the same dilemma we faced when preparing for the MCAT. Some medical schools offer their own reviews, which can be good or bad. KAPLAN offers an expensive review, as they did for the MCAT. My impression is that most people study on their own, from texts, review books (first aid, step up), and do tons of questions (NMS, Qbank). Some students use their own notes from medical school. With the test in recent years presented more and more as clinical vignettes, it is important that your review materials emphasize this approach. The key is that you use the books, in the format you liked best during your first two years.  You must cover everything, but don’t dive too deep into specific topics. Make sure that if you where marginal in certain topics (i.e. micro, pharm) you compensate in your plan to eliminate proficiencies. Don’t be initially overwhelmed with the amount of information you must review. Set a steady consistent pace, and with time great progress can be made, day by day, week, by week (look at the Grand Canyon, although you have a little less time...) Use your reading as a base, but as important is taking practice exams, and reviewing your answers (those that were right as well as those that were wrong). Take notes when reviewing your practice tests, then review these too. I feel as it did for me with the MCAT, this portion of my standardized test preparation is always the most important.

Delaying your exam

This is a difficult topic to assess. You must be very careful and honest to yourself when trying to make this choice. Try to speak to a faculty advisor to assist you. The only reason to delay taking your exam is because you feel that you are not prepared to take the exam, because you were not able to give your preparation 100%. This should not be as a result of a lack of planning, but more as a result of circumstance that may have occurred to throw you off track.

The Cons:

³ You are farther away from the Year 1 and Year 2 where you meticulously learned all the relevant material, and may continue to forget with extended time

³ If you start Year 3, you have even less time to study for step 1 during clerkships. It will become necessary for you to designate several weeks in between clerkships to properly prepare. Taking extra time to study for step 1 in between clerkships will limit opportunity for electives which may become very important late in your 3rd and early 4th year

³ What you learn in preparing for step 1 is very important to a good performance on clerkships in year 3.

The Pros:

³ Giving yourself your best shot

³ Developing a clinical thought process useful in deciphering the clinical vignettes found on step 1 by completing clerkships like medicine and surgery

³ If you are unprepared, and fail the exam, it looks bad, but you can retake it. However, if you are unprepared and marginally pass, it looks bad, but you can’t retake it, and you will greatly limit your residency options.

Most often, delaying your exam will not lead to a better score. However, in rare cases it can. You must be true to your self to make the decision. I must say, I don’t know anyone who felt totally prepared for the exam, and everyone freaks out in the days leading up to it.

How to interpret your Step 1 scores

Upon completion of your exam you will receive a certificate of completion from the test coordinator at your site before you leave. Your score will be mailed to you approximately 6 weeks later. The letter will give you three grades. The first is the easiest to interpret, Pass or Fail. The next two grades are not as easy to interpret, and includes a 3 digit number (with mean, standard deviation, and standard error of measurement), and a 2 digit number (with the number needed on this scale to pass, the 3 digit equivalence of the 2 digit score mark to pass, and the standard error of measurement). The 2 digit number is derived from your 3 digit number, is NOT a percentage, and it is set at a scale that a score of 75 corresponds to the lowest passing score. The 2 digit number is used in score reporting because some medical licensing authorities require a scale describing a "passing score of 75." In Early 2003, the 3 digit pass number was 182, and the average for first-time examinees from US and Canadian Medical schools was approximately 216 with a standard deviation of 24, and standard error of measurement of 6 points.

One Sample Scale of 3-digit Step 1 Scores I came across:

245+ = “A+ or Exceptional” (Approximately 80’s in Qbank)

230-245 = ”A or Great” (Approximately 70’s in Qbank; also, some secretly talk about a cut-off of 230 on Step 1 for many competitive specialties at competitive programs, below which applications are overlooked)

215-230 = ”B or Good” (Approximately 60-70’s in Qbank)

200-215 = ”C or Average” (Average in 2003 was 216, with SD of 24)

182-200 = “D or Pass” (Pass in 2003 was 182; Kaplan talks about a 50-60% on Q-bank to pass Step 1)

Be very careful when looking at the above scores, and the scale. I know that many statisticians may feel this scale is very simplified, and it is.  Also, Step 1 is weighted differently by different programs, and some are considering not using it at all, relying more accurately to determine your potential for the field by grades, evaluations and letters. Lastly, you will find by asking around, that there were students getting 75’s on Qbank who failed the actual exam, so take these figures lightly.

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