My USMLE Step 1 Journey (2024)

Ah, the dreaded USMLE… *shudder*. It is dreaded for a damn good reason. Preparing for this eight hour exam was the most gruelling experience I have undergone in my academic career. It really is mind over matter for this beast: a test of one’s endurance and mental fortitude. In this post, I am going to break down how I studied, what I did the day before and what to expect the day of. An all-inclusive general guide, you could say. This is going to be a lengthy post, so apologies in advance but I do hope it is useful to someone!

I should preface this post by saying my USMLE preparation often felt like a hot MESS. In fact, my first two years of medical school have been an absolute rollercoaster. If you have been following my journey, you will know that I had brain surgery in July 2019 to resect an arteriovenous malformation (AVM). This was discovered when I was admitted to hospital a few weeks into my first semester of med school. Fast forward to second year, where my seven year relationship came to a crashing end, unravelling early in 2020. All of this alongside the unpredictable climate of COVID made for a very stressful, scattered and frankly, depressing few months. I returned home due to COVID-19 in March, but had quite a few of my own demons to deal with. By no means am I perfect or the most organized, Type-A student (I am far from it actually).But I work hard, and for this exam I worked harder than I have ever worked in my life. My advice is based on what worked for me, fully acknowledging that I fell off the grind wagon more than a few times during my dedicated period.But if you are anything like me, I would find solace in knowing that someone else fell off the wagon (more than once), wasn’t capable of grinding like an automated machine, but STILL made it through and did well. So if I can do this, you DEFINITELY can.

Recommended study materials:

• First Aid: This will be your bible during Step prep. It is a dense, fact-filled book that you will keep going back to time and time again.
• Pathoma: Dr. Sattar is a Pathologist who does a phenomenal job at summarising pathology in a clear and concise manner (recommend the book and associated videos)
• Boards and Beyond: Dr. Ryan is also fantastic – his videos are detailed and easy to understand *Note: This resource does go into quite a bit of detail, you really don’t need to memorize every detail in every video(which is what I thought at the beginning). You can pick and choose which videos to watch. Would definitely recommend watching for topics you are weak in (ex: embryology!)
• Sketchy Micro and Pharmacology: I was not a Sketchy believer at the start but after realizing how much more I was retaining using the videos and associated images, I stuck with it – DEFINITELY recommend for Micro – Can get a little overwhelming with Pharm but again, I stuck with it and it did really work for me
• Anki flashcard app: There are pre-made Anki decks that go with the associated study resources – I am not great with Anki, so feel free to ask any questions but I would recommend looking upAnkingon YouTube and searching theReddit Anki thread – I downloaded the Amboss plug-in for the Anki app and its super useful, highly recommend!
• Decks I used for Anki: – Pepper Deck (Sketchy Micro & Pharm); Lightyear deck (has all the material from Boards and Beyond although some people used Zanki since it has all the micro/pharm decks combined – depends on your preference) ; Duke (Pathoma cards separated by chapters) ; 100 anatomy concepts (I never actually went through this entirely but I know others who did and said it was helpful)
• Dirty Medicine YouTube channel: I found this channel just a few weeks before my exam and wish I knew about it sooner – The creator gives awesome tips, tricks and super helpful neumonics with a focus on only the high yield USMLE material – I really loved his videos for Biochem, Genetics and Immunology. Highly recommend!
• USMLE Rx: This is a cool resource that is linked to First Aid – It has pre-made flash cards and questions for each section of First Aid
• Pixorize: popular resource for BiochemSame format as Sketchy micro – each concept has an associated picture – I didn’t personally love Pixorize, but it works for some people & there is an associated slide deck that you can download to Anki – I would recommend watching Dirty USMLE’s videos for Biochem if pictures aren’t your thing!
• Dr. Goljan’s audio files: Can be found on Spotify (search Goljan audio). Dr. Goljan is the King of USMLE Board Review. He is a highly revered Pathologist situated in the US. His audio files are recorded from his Step 1 board review sessions and his insight is GREAT because he is a question writer for the exams too. HIGHLY recommend, especially if you are taking a break to go for a walk or driving.
• Dr. Goljan’s high yield document: This is a 36 page document that you will hear him refer to constantly in the audio files – He promises that if you know everything in that document, you will get a great score (can be found at this link: http://shortwhitecoats.com/wp-content/uploads/2011/09/Goljan-High-Yield.pdf)
• Uworld Q-bank (3221 questions in total): this is a must do during your dedicated study period. Use it as a learning and testing tool and do questions in 40Q blocks to simulate the real exam.
• Amboss: I only used Amboss when I needed a better explanation and First Aid wasn’t cutting it for me (definitely wasn’t a regularly used resource). They have great summaries and tables.
• UWORLD High Yield Doc: A friend found this crazy resource off of Reddit. Somebody compiled every question in Uworld and organized it based on yield and system – I found this to be SUPER helpful especially towards the end… I would skim through the document to make sure I understood the high yield concepts(find it here https://www.reddit.com/r/step1/comments/dunue3/hi_i_did_a_thing_uworld_topic_yield_spread/)
• Use these pretty checklists someone made to keep track of your Sketchy Micro/Pharm/Pathoma videos (https://www.reddit.com/r/medicalschool/comments/76coin/pathoma_and_sketchy_pharm_to_do_lists_printables/)
• Cram Fighter – is a scheduling app that will input all of your resources and timelines & churn out a daily schedule (I didn’t use it that much but other people love this tool)

During the MS2 school year:

I first cracked open First Aid and Pathoma in September, a full year before my exam. These two will really be your bible during your Step 1 preparation. At RCSI, the first semester of MS2 covers Cardiology, Pulmonary and GI systems. Second semester covers Renal, Endocrine, Genitourinary, Breast (in one massive module we call REGUB), Neurology, MSK and Infectious Diseases. My goal for the year was to cover majority of the STEP 1 material at least once, including Microbiology and Pharmacology.For each system we covered at RCSI, I would concurrently cover the associated Step material.

To use cardiology as an example:

• I made a list of all of the Boards and Beyond videos, the number of pages I had to cover in both First Aid and Pathoma
• I divided the total pages and videos up by the number of days I had for each module and that was my daily schedule (although this was never set in stone)
• I did more or less of what I needed to depending on how I was feeling that day….some day’s you need to just turn off your brain and watch Netflix…we’ve all been there)
• Our cardiology module was a month long. I aimed to finish the bulk of the Step material within 3.5 weeks, giving myself half a week to review solely RCSI material before our end of module exam.
• As I watched Boards and Beyond & Pathoma videos, I annotated each book with notes that would be useful during the dedicated study period.
• Having gone through this whole process now, I would recommend watching Pathoma videos first as he sets a very clear and concise foundation, and then going back and watch Boards and Beyond for topics you need more clarity on (you will soon realize you don’t have time for everything)
• After having gone through our first module, I realized getting through all the material was tough. Myself and two other friends divided up the Boards and Beyond videos from this point on, typed them up and compiled them. Would recommend! I skimmed these summaries during MS2 finals and dedicated.
• I used Anki Lightyear, Duke Pathoma and the Pepper Micro/Pharm decks during the year – although I never could keep up. Anki is a beast! If you had to prioritize I would say keep up with Micro and Pharm. I wish I could tell you I did x number of cards daily, but I was all over the place, some days hitting 0 cards, others hitting 900 cards.
• I have always found making summary sheets super helpful. Especially in second semester of MS2, I began making summary sheets for major topics so that I could easily skim a concept without having to go back to my textbooks. I have included a picture below so you can see what I mean:
• I would highly recommend incorporating Dirty Medicine YouTube videos into your studying – he has great tips for memorizing material!

In terms of Micro & Pharm:

• I started Microbiology in October and would watch videos whenever I had time
• I made my way slowly through all of Microbiology within a few months and kept up with the associated Anki flash cards (Pepper Deck is good or ‘lolnotacop’)
• I started and stopped Sketchy Pharm so many times during the year. I just could not be bothered. I did eventually finish my first round of it by June
• I would definitely recommend getting Sketchy Pharm done before your dedicated period since it will clear up a lot of precious studying time!

In summary, MS2 study days would more or less consist of heading to classes/tutorials and then hitting the books. Watching my scheduled Pathoma, Boards and Beyond, Sketchy videos for the day, making my summary sheets, doing my flash cards and testing myself with questions on USMLE Rx. I won’t sugar coat it, MS2 is intense because of this juggling act. I think it is better to be realistic and know what you are getting into so you can mentally prepare for that! You will have good and bad days. Don’t get overwhelmed by what you don’t know. The first pass through Step material is meant to lay a strong foundation with the high yield, overarching concepts. Try not to get buried by the nitty-gritty details!And remember, we have all done this and you WILL too! Don’t forget to reach out if you ever need help or advice (we are all so happy to help, we have been there and 10000% understand how it feels) & rely on your support system.

My journey through dedicated:

I’m not going to post a specific schedule for dedicated because I honestly didn’t really have one. By that I mean, my Cram Fighter was always populating a schedule, but I could never keep up. I found it more discouraging than anything so I decided to abandon that and create my own loose timelines. I knew I wanted to finish content review three weeks before my exam. I was aiming to finish the Uworld question bank a week before my exam. I had scheduled in 5-7 practice exams, time permitting.My dedicated period was supposed to be from mid-June to end of August.

I can honestly say I do not know where June and July went. We had our MS2 finals in May and I never really took a proper break. I was thoroughly burnt out at the beginning of dedicated and I think that definitely played into my inability to focus well in June and July. My focus in June was on reviewing material and starting to do Uworld blocks. I had a string of unfocused, unproductive study days throughout June and July. My schedule was also uprooted when I had to head to Calgary for my one year surgery follow up. I realized I needed a bit of a break, so I took a few days completely off to reset because the burnout was threatening to swallow me whole.

Before I knew it, it was the third week of July and I did NOT feel prepared to write my exam on August 31.

• I wrote my baseline NBME (NBME 15) on July 27 and scored a 186, which is a FAIL. I should have really written this sooner because nothing else other than failing an NBME would have successfully kicked my ass into high gear. I cried more than my 6 month old niece that day and considered quitting because I was genuinely concerned I was going to fail at this rate. But my sisters picked me back up and reminded me that I can push the exam and still have a solid 6-7 weeks to GRIND. I just needed to regroup. So that is what I did.
• I logged in to the Prometric site and rebooked my exam (all done online) for September 15. This gave me an extra two weeks.
• After three weeks of grinding through material I was weak on and getting through many UWorld blocks, I wrote NBME 17 on August 19 (three weeks later) and scored a 209
• Wrote UW1 on September 1 and scored a 230
• Wrote UW2 on September 8 and scored a 239
• Wrote NBME 18 on Sept 12 and scored 228
• Exam date was September 15: Final score was 234

Here are some tips for dedicated period based on my experience:

• Start Uworld early and use it as a learning tool. Don’t wait until you have covered enough material to start doing questions (this is a MAJOR mistake!)
• Start by doing one 40 question block a day (timed and on RANDOM mode – not tutor). After you have finished a block, take a 15 minute break (grab a coffee & snack) and sit down and review your questions properly while your thought process for each question is fresh in your mind
• Ideally you want to be hitting at least 2 blocks (80 questions) daily with review, but this depends on the length of time you have for dedicated period and whether you want to get through the Uworld bank once or twice (I only went through it once – and actually had 900 questions left to cover that I decided to forgo for the sake of my mental health- this is where the UW High Yield Excel spreadsheet came in handy). You get faster at reviewing blocks with time. And you can choose to only review your incorrect questions. Whatever you are comfortable with.
  • If you start to feel overwhelmed with UWorld questions, just remember that any amount of practice is better than nothing. Even if that means doing 5-10 questions a day.
• For questions you really don’t know or understand, I would recommend making your own flashcards either in the UWorld website itself or on Anki so that you can continue to review concepts you may be weak in. I only did this for a few weeks, but I do wish I had prioritised this more looking back.
• Would DEFINITELY recommend getting through all of Uworld. But don’t feel sh*tty if you don’t, I didn’t and I made it through just fine.
• Do whatever you find the most challenging first thing in the morning. For me, that would be UWorld blocks. In terms of covering content, everyone has a different approach. Some people divided up First Aid by the number of days they had for content (my goal was to finish content 2 weeks before the exam) and committed to finishing those pages daily.
  • I personally scheduled a few days each for the various systems (ex: 3 days Cardio, 2 days MSK, 3 days Neuro, etc.)
  • I sprinkled in an hour Pysch here and there as opposed to giving it dedicated days
  • I covered Biochem thoroughly in June and had to spend 3ish days re-reviewing it in August. I would recommend keeping up with Biochem via flashcards. I would also definitely recommend drawing out all of the pathways repeatedly and scheduling time weekly to do that. I bought a white board and would spend 2-3 hours throughout the weeks from August onwards drawing and re-drawing the various pathways & reviewing the clinical diseases.
  • My summary sheets saved me during the last 3-4 weeks of my prep. I stopped referring to First Aid and solely used my summary sheets to review concepts. If I really needed an extra resource, I would skim through Pathoma.
  • Watching videos can be really time consuming. I would save it for topics that you need extra help in to save time. USE DIRTY MEDICINE YOUTUBE CHANNEL!!!!
  • Make a list of what you are weak on (ex: heart murmurs, neuro motor pathways, glomerular diseases, etc.) and hone in on these. Check them off as you start to understand them
    • For the topics I felt especially weak in, I found it helpful to do UWorld questions specific for those (ex: selecting only heart sounds, murmurs, cardio anatomy, etc.). This isn’t a waste of questions and can really help to solidify your learning!
  • Listen to Goljan Audio!!! He has amazing pearls of wisdom to share. I would listen while I got up and brushed my teeth, while going on a walk, while driving to grab a coffee, etc.
  • You could spend endless days covering content. And you will actually never feel ready in terms of knowing all the content. It just isn’t physically possible and this test is designed to make you feel like you aren’t ready. Try to be firm with your personal deadlines (try to finish up content by the date that you intended) and then really focus on bolstering your weak spots and getting as much practice as possible.
  • Don’t leave Micro and Pharm until the end. Get started on this EARLY and keep up with it using flashcards. I printed these beautiful checklist sheets and went through all of micro and pharm 2-3 times over the course of the year and dedicated period.
    • If you get in a rut and realise you have abandoned your micro/pharm Anki cards (I did this so many times, don’t feel bad), then suspend ALL of your micro or pharm cards and release only a section at a time once you have covered the material.
    • For example, I suspended all my Pharm cards and decided to re-start with Anti-microbials. I would read through my Sketchy Pharm notes for each video (and watch the videos for the drugs I was struggling with on 2x the speed) and then un-suspend each video’s Anki cards as I did them. Check off what you are doing using these awesome checklists that someone posted on Reddit (access the checklists here https://www.reddit.com/r/medicalschool/comments/76coin/pathoma_and_sketchy_pharm_to_do_lists_printables/ ) and you will slowly regain control again! This approach really worked for my friends and I!
  • The NBMEs suck to be honest.
  • Write a baseline NBME ASAP. The sooner you do, the sooner you will kick yourself into high gear and recognise what your weak points are. Don’t fret over the score even if it is a failing one! This is just your starting point and gives you a good measure of your progress.
  • I had intended to do a practice exam weekly or every 10 days, but after failing my baseline exam, I knew I was too weak on content in too many domains to write another. I also factored in the potential of having another massive panic meltdown and decided I was better off spending 2-3 weeks really hammering home material and then writing another to see if I had truly progressed. My score improved by 23 points in 3 weeks. That was really motivating for me and a good lesson that you can make massive improvement in a short amount of time, so don’t feel discouraged!
  • Decide how many practice exams you want to do and schedule them in accordingly. DO NOT write a practice exam within 2-3 days of your actual exam date. I did this and was really frustrated….do NOT RECOMMEND.
  • There is no point in writing a practice exam if you don’t sit down and review it. Try to review your practice exam within a day of writing it (it will take you a few hours). Unfortunately, the NBME exam banks will only tell you that you got the question wrong. You have to look up the questions on Google (Reddit, mynbmeanswers.com, student doctor network were all good places to find the answers).
  • The practice exams only have four blocks to them, so if you want to simulate the length of the actual exam, add on 2-33 blocks of UWorld depending on the practice exam you are writing.
  • Try to simulate the actual exam for at least 2 of your practice exams. Take breaks only when scheduled (between blocks) for the amount of time you would during the exam. Don’t eat or drink during the practice exam. This exam is largely about stamina as well, so you need to practice this. If you are someone who gets really anxious or worried about how the previous block went, you will need to start practicing some calming techniques that will allow you to reset between blocks on the actual exam (I would do a 30 second prayer, a few deep breaths, jump squats, jump up and down shaking like a wild woman & then resume like the composed graceful woman that I am 😉 ).
  • The practice exams everyone writes:
    • UWorld Self Assessment 1
    • UWorld Self Assessment 2: Also thought to be more predictive so save for the end
    • NBME 18: Is thought to be more predictive so save for the end (I wrote this 3 days before)
    • Free 120
    • Whichever other ones you decide to write is up to you! As of right now, NBME 20-23 are not free ($60 each). NBME 13, 15, 16, 17, 18 and 19 are currently free on the http://www.mynbme.com website.
      • ***Beware, NBME 19 is known to be brutal, so don’t be too alarmed if your score is really low***
      • From what I read online, NBME 13, 15 and 16 are all good baseline exams

An important note about mental health:

I think it is fantastic that the USMLE is moving to pass/fail in 2022.This exam is honestly like nothing I have ever experienced. We were warned that it was going to be tough, but I didn’t take it THAT seriously. I didn’t imagine that it would impact me in the way that it did. I wish more people would talk about how much of a toll it can take on your mental health. Everyone in my circle really struggled mentally with this exam. Personally, I cried daily. Some days I couldn’t even muster the energy to converse with my family or smile. I have never felt as soul-suckingly low as I did during my dedicated prep (this was also coupled with the mental stress of COVID-19).

So please don’t take this piece lightly. Take care of yourself. Check in on your friends. Don’t isolate yourself out of anxiety and stress like I did. Schedule in fun for yourself. And also know when you are at the end of your line. NOTHING is worth sacrificing your health over. There will ALWAYS be an option no matter what happens, no matter how this exam goes. Medicine is beautiful in that way…there are so many doors and pathways to make your dreams a reality (I mean, hello, I am sitting here writing in Dublin, Ireland as a Canadian gal!). So be kind to yourself. Don’t beat yourself up if you aren’t hitting your goals, aren’t able to get through x number of questions or aren’t reaching your ideal scores. Take a break. Take a few days off to recuperate. Allow yourself to mentally turn off the USMLE burden and make time to do the things that you ENJOY, the things that light your soul on fire.

And I’m just going to repeat this because I really do think it is not said enough and there are many people who may need to hear it: you are NOT your score. How you do on this exam will not dictate your trajectory in life. Yes, it may make things easier or harder. But there is ALWAYS a way. Please don’t forget that. And don’t sacrifice your wellbeing for it.

Few days before:

Two days before your examination, you should receive a confirmation call from Prometric. They will confirm your time of exam and ask you to arrive at a specific time.You definitely want to start winding down at least 2 days before your exam. Get in the habit of going to bed early and waking up early at the time you would for your exam at least a week beforehand if possible. I made the mistake of grinding all the way up to the day before…I couldn’t sleep the night before the exam which exponentially increased my anxiety the morning of. I really recommend taking the day before the exam completely off. You will need it because exam day is gruelling.

What to expect the day of:

My exam time was scheduled for 8AM and I was told to arrive at 715am. I woke up at 530am after a rather sleepless night plagued with tossing nervously back and forth. I was actually in very high spirits surprisingly! I blasted my tunes and drank a cup of coffee while perusing through my Sketchy Micro book. I left a bit early so that I could hit Starbucks on the way.

• I bought two coffees (one for now and one for later in the exam) and put them both into to-go mugs that I brought from home. I recommend doing this if you are a coffee drinker because you won’t have an option to leave during the exam. I also bought their feta egg white wrap for lunch which was light & luckily didn’t make me feel drowsy during the exam
• I arrived to the testing center by 715am on the dot and had to wait (socially distanced of course) in a line to be processed. Arrive early if you can. You get to start as soon as you are cleared.
• You have to wear a mask from the moment you enter the testing site, be sure to bring one! I had a cloth one and a back up one just in case. They will approach you during the exam if they see you aren’t wearing yours.
• On arrival, you will be asked to show your ID (I brought my passport, but a license will suffice) and your USMLE scheduling permit (be sure to print this off the night before).
• You will be given a locker to store your belongings. My testing center also had cubbies where you could place food and drinks for quick access during breaks. Unfortunately, no liquids or food are allowed in the room, including water.
• After storing my belongings, I entered a room where I was asked to once again show my ID, sign a form and have my photo taken. I was asked to show the contents of my pockets, hood, roll up my sleeves and pants.
• You will be given a unique identifying number (CIN) that is on your scheduling permit. They will ask you to write it on your scratch paper the day of. You are only allowed to bring in this scratch paper, a pencil (that they provide) and ear plugs.
• They will provide headphones at each station.The stations are set up like cubicles. As soon as you sit down you will be prompted to input your unique ID number. Every time you enter and leave the room you will be required to re-enter this ID number.
• There is a 15 minute tutorial that you may do. I quickly checked that my headphones worked and then skipped the tutorial,as this 15 minutes can be added to your 45 minutes of break time, giving you a total of 60 minutes during the day!
• And you are OFF!The format is just like Uworld— there is a search bar for the lab values too.
• You have 60 minutes for each 40 question block
• There are 7 blocks you have a total of 8 hours for the exam which includes 60 minutes of break time (provided you skip through the 15 minute tutorial at the start)
• I took a break after every block as I could feel myself getting panicked towards the end of each block. I needed to walk that off and reset before starting the next block. I literally did squat jumps in the bathroom. I even cried in between a block…you do you. I preferred taking a shorter “lunch” and instead gave myself more time for the other breaks.
• During each break, I would take swig of coffee, grab a handful of snacks (I had a trailmix & my favourite chocolate) and a bit of water. I would also run to the bathroom because you can’t take a break during a block.
• My break schedule:
  • Between blocks 1 and 2: I took about 6-7 minutes – this includes the time it takes to get in and out of the room, re-enter ID number into computer and start the block
  • Between blocks 2 and 3: I took almost 10 minutes – my second block was rough and I needed the time to quickly cry it out and reset
  • Between blocks 3 and 4: 7-8 minutes
  • After block 4 I took a 15 minute lunch break
  • Between blocks 5 and 6: about 10 minutes
  • Between blocks 6 and 7: 6-7 minutes

And after eight exhausting hours, it’s over. The day’s emotions just poured through me as I left the center. I bawled for a whole hour after. From what I hear, it’s pretty normal to feel like sh*t post exam. You will likely walk away feeling very uncertain of how you did. It is normal, we all felt that way! Take your time to decompress and then celebrate!

Getting through STEP 1 is no small feat.

You will get an email notifying you that our score is available. From what I am hearing, it appears that scores are released on Wednesdays, within 1.5-2 weeks of your exam date. If you are in need of advice or just need someone to pull you back up, comment below OR send me a message @sincerelymillie on IG! You GOT this 🙂