Making a Physician: the USMLE STEP 1

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The ISTEP, the SAT, the MCAT, and now the USMLE. These are a series of acronyms that evoke a primal, almost nauseating response among those of us that have fought the gauntlet of standardized testing for the majority of our lives. It is monumental tests like this: single-day, multiple-hour, multiple-subject, and multiple headache-inducing exams that convert you into a number and have a huge impact on your life. The most recent of these battles along my educational quest was the United States Medical Licensing Exam Step 1. I’ve been waiting to write an article about STEP 1 for awhile, both to get down my thoughts about it as well as provide another insight into all the hoops one must jump through to become a practicing physician. The reason I waited until now to do it was that I got my results a few days ago. I didn’t write this immediately after the result release is because the salt in this post would have reached Dead Sea levels. With my results in hand (or rather, in computer), I can finally bring this chapter of my life to a close, as well as actually bring my thoughts full circle. Come, let’s journey on.


What is STEP 1 (baby, don’t hurt me)?


So go figure, a massive intellectual undertaking such as becoming a physician requires tests. Lots of them. Please feel free to pick your cerebrum off the floor after me blowing your mind. Over the past two years, I’ve been tested until my eyes bled (metaphorically), until my butt grew a cyst (literally), and until my psyche can’t fathom another multiple choice question. I’ve also missed more questions in the past two years than I probably have the rest of my academic life combined. Not sure if that’s actually saying something, but it’s out there. However, most of these tests are ran by our home institution, with a handful of them (called NBME or shelf exams) are ones that are nationally standardized that we take during our final exam period. The NBME (National Board of Medical Examiners) compiles all of these, and they usually serve as our “final” for a given class. This organization is also responsible for licensing physicians, which involves testing medical students to death. Their first big assessment of us after our first two years of school is the abomination of an exam called STEP 1.

To put it in basic terms, STEP 1 (yes, there are STEP 2 and 3 also. Boom, numbers) is basically the MCAT of the residency application. What is residency, you ask? It is a program anywhere from 2-7+ years that trains graduated medical students to practice on our own. We are doctors when we graduate medical school, we are just not licensed to do medicine by ourselves. We must undergo extensive training (kind of like an apprenticeship) in order to learn the trade of a particular specialty, whether that be emergency medicine, orthopedic surgery, or pediatrics; only then are we allowed to become full-fledged doctors (after passing our specialty’s boards, of course). Just when we thought we were done jumping through hoops by taking standardized tests, logging research, volunteer, and work activities, crafting shiny attempts at an original personal statement, filling out massive applications, and going to interviews, SURPRISE! YOU HAVE TO DO IT AGAIN! Just like the process of getting into college, and then getting into medical school, the same, tired story plays out with applying for residency. It includes all of our favorite elements: paying exorbitant fees, traveling to interviews (again, more money), taking a bunch of tests, trying to buff your application with extracurricular activities, and having people judge you and your entire existence off of a dozen sheets of paper and maybe 20-30 minutes of face time. I’m not saying that there’s some better way of selecting applicants, but I’m just pointing out some of the facts of how our current education system runs. Don’t mistake that for me being a Negative Nancy about things. I’ve learned to accept that.


What does STEP 1 cover?


STEP 1 is taken between the 2nd and 3rd years of medical school, and marks the transition between the pre-clinical (i.e. spend 8 hours of day in lectures, followed by 6+ hours of studying, rinse and repeat) to the clinical years (working in the hospital, rotating through different specialties, and learning under the tutelage of residents and faculty). It encompasses everything that we learn the first two years of medical school. People, that’s a ton of information. The joke is that medical school is like trying to drink from a fire hose. You try and gulp down what you can, which isn’t much compared to the massive amount of information sprayed in your face.. I’ve maintained that I learned more in a day of medical school than in a week of undergrad, and that’s probably not far from the truth. Let’s take a moment to examine what drinking from a fire hose is actually like, and what it’d be like to “gulp” down that information over two years: a fire hose can output up to 250 gallons of water per minute. That means 15,000 gallons per hour, 360,000 gallons per day, and 260.64 million gallons over 2 years worth (i.e. first two years of medical school). For the sake of somewhat realism, we can say there’s about 8 hours of information per day, so we can take 1/3 of the total to give us about 87 million gallons of water (or rather, information) over two years worth. A human male is recommended to have about 0.8 gallons of water per day (like anyone really drinks that much, but we’ll use it for just the sake of math). That’d mean it would take 108.75 million days, or about 300,000 years, to gulp down that much water. You might be able to cut it down to 150,000 by doubling water intake to insane levels, but I think that sufficiently describes the point I’m making. While a bit overkill, it kind of shows (in an absurd, unrealistic manner) just how much us lowly medical students are trying to learn.

Our first two years of medical school cover the so-called “basic sciences” (I laugh at the use of the word “basic” every time) about the normal (1st year) and abnormal (2nd year) human body. My first year classes included microbiology (aka what organisms get us sick), immunology (how we fight infection), histology (lots of microscope time looking at cells and learning about them), biochemistry (something something signaling pathways), anatomy (there are how many things in the body?!), physiology (basically just lots of up and down arrows), neuroanatomy (my head hurts just thinking about the brain), and an intro to clinical medicine course (real doctor stuff, kind of). My second year courses included pathology (the study of disease), pharmacology (more memorization than you ever though possible, and who the heck comes up with these drug names?), genetics, biostatistics/evidenced based medicine (is this scientific study good or total horse crap?) and medicine (basically applying course matter to the clinical world). STEP 1 covers all of these subjects and then some, in a level of excruciating detail.


What is the test like?


This exam is an 8 hour, 308 (formerly 322) question multiple choice, one-best-answer exam. It is given in 7 one hour blocks of 44 questions with 1 hour of total break time to be used at the examinee’s discretion. To put that into comparison, the MCAT was about 5 hours when I took it (I believe it’s near 6.5-7 hours now). People, it’s a long exam. It requires your brain to be firing at an insane rate question after question, hour after hour, in order to perform your best. The questions have a certain subject or area that they are focused on, but they require a global understanding of many medical concepts to put an entire answer together. There aren’t specific sections to the exam, as subjects are intermixed from question to question; these questions also require quick thinking, as you have 44 questions in 60 minutes. The questions begin with a so-called “clinical vignette” that describes a patient and some kind of scenario related to them, then finished with a one-sentence question and anywhere from 5-15 possible answers (usually only 5-6 choices, however). The vignettes are the exam’s way of attempting to take questions such as “what enzyme is deficient in fructose intolerance?” and disguise it as:

“A parent comes into the clinic with their 1 year old male child, who exhibits vomiting and lethargy. They have recently moved to another country and have started transitioning him to new foods. They are concerned about his symptoms, as they say he has not experienced anything like this before. Total bilirubin is 3.2. AST is 101 and ALT is 240. Hemoglobin is 13.0, hematocrit 38, white blood cell count 11,000, temperature 37C, HR 110, BP 95/65, respiration rate 23. Upon physical exam, the infant has a yellow tint to his eyes and is obtunded. What accumulates due to the enzymatic deficiency in this patient?”

While this is a very poorly written question (because I’m no exam writer. If you want to see real practice questions from STEP 1, go here.), it showcases a few things that this exam tries to do:

1. Multi-step questions: STEP 1 very rarely asks you “what is this thing?” and moreso tends towards “what is the thing associated with this thing?”. It is what we’ve come to call “multi-step thinking” or multi-step reasoning. In this case, it’s not enough to just know, “oh, this kid has fructose intolerance.” You must first realize what disease the child has, then what enzyme is deficient in this process, and then what is the substrate that this enzyme breaks down (in this case, it is fructose-1-phosphate). This question could have gone a step further and asked why there is liver damage in this kid (as indicated by his elevated AST/ALT enzymes, which are markers of liver damage), and that’s because there is a decrease in available phosphate. It’s this kind of questioning that forces us to know each and every detail of many processes, because nailing the correct diagnosis is 95% of the time not sufficient to answer the question.

2. Details: STEP 1 is very big on small details. While the MCAT is more of a critical reasoning exam, with I’d say 75% being critical reasoning and 25% being memorization, STEP 1 tends toward more of a 50% critical thinking, 50% memorization (I’d even argue it’s 60% or 70% memorization in some cases). While you have to be able to think and reason, this exam is very much about cramming as many details into your head as possible. A lot of the time, these details are not exactly essential in clinical practice.

3. Distraction: The clinical vignette often tries to distract or put up an illusion of what the question is actually about. There are many lab values (i.e. the hemoglobin) that are completely normal and do not contribute to this question at all. While the question here is a short one, the vignettes can be two or three paragraphs long. Digesting all of this information can prove to be tricky, and often 50% or more of it is simply there to distract you from the right answer. This is why most students (including myself) have come to read the last two sentences and the answer choices first, then the clinical vignette, in order to have an idea of what information we are supposed to glean from the vignette.

4. Obscure concepts: This exam is designed in order to stratify a very intellectually/academically talented and hardworking group into 3-digit numbers. We’re a group that is known to perform well on tests. Nearly any medical student will be able to tell you what side of the heart is failing if someone’s legs are swelling, but not every one will be able to determine how the hydrostatic and osmotic forces are balanced in this situation that cause the edema. The NBME must ask difficult questions on subjects that don’t necessarily matter in clinical practice in order to let only the best students truly stand out. This again is mostly because our education is designed to teach us every process from the very smallest to very largest level in the human body, but it allows for a gigantic breadth of questions to be asked on minute details. These can include things like knowing the particular genetic translocations in follicular cell lymphoma versus Burkitt’s lymphoma versus chronic myeloid leukemia, etc.

And this exam is 8 hours of these type of head pounding questions. No matter what type of super-human endurance an exam-taker has, it is difficult to keep up an insane pace for so long.


How do students (and how did I) prepare for STEP 1?


While this type of question necessitates a blog post all its own, I’ll go through the highlights. To make a long story short, there are 3 things that are considered the holy grail of studying: USMLEWorld Qbank, Pathoma, and First Aid for the USMLE STEP 1. First aid is a hyper-condensed version of all of the information a second year student should know for the exam, in so much as every single sentence could be an answer to a question. Pathoma is a video-lecture series that explains pathology in a very simplistic, conceptual manner. It’s essential because pathology is the most heavily tested subject on STEP 1. Qbank is a question bank that very closely mimics the real exam, and provides excellent explanations that provide more learning than the question itself. There are many, many other resources out there, including other question banks, review books, flashcards, etc, that different students use depending on what they need. Those 3 were the main resources I used, in conjunction with the First Aid Qmax question bank. Students dedicate a large amount of time to studying for this exam, and ramp it up as they get close to taking it; this is often during April-July between their second and third years. I had one month off between the two years, so I took my exam 2.5 weeks after my last final ended, giving me 10 days to rest up before third year. To me, that was the perfect amount of time.

I ended up fervently reviewing and going through all of Pathoma, reading and trying to master first aid sections, and doing questions fairly heavily for the 6th months leading up to the exam. I had to go back and essentially re-learn most of my first year material while attempting to review, so it was a challenge, as it was for any student. I did the entire USMLEWorld Qbank (about 2200 questions) once through, then did all my missed questions (which were somewhere near 800-1000) until I got them all correct, then I did all of Qbank again. I also did the entire First Aid Qmax question bank as well, about 2,400 questions. Studying from these involves doing the question and reading every answer choice meticulously, especially the incorrect ones, in order to learn the concepts; then I would go back and review the relevant material from First Aid. It’s a very time consuming process, but I did the better part of 8,000+ questions. Every student has their own method, but I thought that was what would work for me.


Why does STEP 1 matter?


The key piece of information to understand why this single exam is so important has to do with medical school grading: most medical schools nowadays are pass/fail. The traditional grading system of A-F used to be in place at a lot of institutions. However, I’m pretty sure it’s not difficult to understand that if you take some of the most compulsive, high-achieving, competitive people, who often succeed due to these traits, and put them in an environment where they must fight each other to get good grades (if there is a bell-curve distribution) to get into good residencies, it doesn’t do well for mental health. We are stressed out enough most of the time. Most schools have taken to a pass/fail system, or a modified form. Here at Indiana University School of Medicine, we have a Pass/High Pass/Honors/Fail grading scale. There is an element of stratification here, as approximately the top 10% of the class is honors and the next 30-40% are high-pass; being at regional campuses with 20-30 students can even work against people trying to achieve high pass or honors, where they would have a much better shot at being in the top half in a class of 200 at the Indianapolis campus. There are current talks to move to strictly pass/fail, but we’ll see how that goes. However, this is the zinger: not all medical schools have the same system. That means that there is little way to standardize across medical schools in order to compare students. Let’s move on to why that fact is important:

Residency programs are selective, and some specialties want only the best students

What this means is that residency programs need to find a way to separate students, and objectively compare them across institutions, since they will have students from all parts of the nation applying for their limited number of spots. If the grades at Indiana University are different than Harvard or Illinois, and those students don’t have the same professors or classes or any of that, how are they to compare us against each other? The answer, as you can already guess, is STEP 1. Those first two years of learning are condensed into this one nationally standardized test that allows these programs to see where we stack up on an intellectual level. It allows them to let separate and quantify us, and see just how well we prepared/how smart we are.


How is STEP 1 scored?


A STEP 1 score is converted into a 3 digit number somewhere between 0-300, with the average being approximately 230 (it’s been creeping up from the high 210’s over the past decade or so). The standard deviation is about 20 points, and the passing score is 192. That means that the top 50% of students are 230 or above, the top 17% are 250 or above, and the top 2.5% are 270 or above. There is a list of average STEP 1 scores, along with a ton of other applicant data, on Charting Outcomes in the Match, which is a yearly compiled document on all the people who applied to residency in that given year. There are averages for each specialty, which can range from 210 for family medicine, 232 for general surgery, or about 250 for otolaryngology (ENT) or plastic surgery.


Okay, I get it…but why is this a big deal?


Not everyone matches into the specialty they want. That’s the kicker. If you want to do orthopedic surgery, they had 994 applicants apply for 695 spots in 2014 (the 2015 data isn’t available), which means almost one third of applicants didn’t match into the specialty they wanted. If you had a 215 STEP 1 score and applied to orthopedics, chances are your application won’t even get looked at, regardless of what else is on it.  It is a single, numerical way of putting two years of the hardest work of your life into a 3 digit number. Certain specialties become essentially out of reach if your score is too low, and certain desired locations or program (think Harvard at Massachusetts General Hospital, or California with UCLA or UCSD, or some big academic center like the Mayo Clinic, etc.) become much more likely with a higher score. About two weeks ago, I had a resident tell me that “your STEP 1 score is the most important part of your residency application.” We apply after our 3rd year of school, so they only have 3 years of work to go on. If 2 of those are represented by this one test, then it makes up a gigantic part of the strength of your application.

Basically, it’s a big f*cking deal. There’s no lighter way of putting that. I hope that I’ve established the significance of this test by this point, as well as given you a little bit into why medical students at the end of their second year go a little bit crazy with this exam breathing down their necks. It’s stressful, no doubt, and we signed up for it by going to medical school, but it doesn’t take away from the fact that it’s this massive weight and stressor on our lives. Here’s the point where if you’re just looking for information about the exam and don’t want to delve into my thoughts (or really don’t care about knowing my score), you can stop here. I’m going to bring this to more of a discussion about me, with less facts and numbers and more about thoughts and feelings.



So, how did STEP 1 go for you, Brandon? 


Well, I took my exam at the end of May, and on July 8th (this past Wednesday), all of the scores were released for anyone who took the exam before about June 22nd or so. It was one heck of a day. I’m going to preface everything with this statement: I hate studying. Plain and simple. I know nobody likes it (generally), but the process of sitting down and reading from some textbook, or grinding out flashcards or lectures trying to understand some concept just irks me. That type of learning style doesn’t cater well to me specifically. I love to learn by doing, and above all I really dislike just memorizing things. There was a reason I majored in mathematics in undergrad and found physics and organic chemistry enjoyable: they require minimal memorization relative to the amount of critical thinking required. You have to learn and understand concepts, sure, but most of it is grinding through real problems using your knowledge, then going in and performing on test day. Memorizing things in math gets you maybe 10% of the way, it’s your thinking and ability to improvise using your tools that gets you through. Biology, on the other hand (at least from an undergraduate perspective) is very heavy on memorization and simply knowing facts. Sure, I did fine in undergrad biology because I got lucky enough to win the genetic lottery from an intellectual standpoint, and therefore didn’t have to work as hard to memorize things, but it was still a challenge for me. I destroyed organic chemistry, physics, and math simply because I knew how to think. I had honed that skill, and my memorization skill kind of capped off. I think that reaches a critical limit at some point.

Getting through medical school has been incredibly difficult, especially the first two years. They are incredibly heavy on lectures, book learning, reading, and straight-up memorizing things. To be honest, I found the critical thinking side of things to be relatively lacking, save for physiology and a few other select areas. While real medicine requires much more thinking and problem solving, first year (and second year, to some extent) felt a lot like swallowing information and regurgitating it. The thing is, a massive knowledge base is required to understand and even begin to problem solve in medicine. I am fully aware of that, and accept that as a fact. If you don’t have the background necessary to understand what a CBC means and what the types of leukemia and their symptoms, signs, and lab values are, you can’t even begin to start thinking about your patient presenting with progressive fatigue and frequent infections. The jury is still out on the best way to present that information and process it, but it came down to just shoving things into my head.

This proved to be challenging, considering the shift to this memorization-heavy education. I almost failed 2 classes my 1st year of medical school. That’s how bad my studying process was for this type of learning. However, I picked it up and felt like I was really hitting my stride come the end of second year. I actually missed out on 3 higher grades in all 3 of my big classes by a total of less than 20 points, so I was the person on the wrong side of the fence by 5-6 points for each class. It was unfortunate, but at least I knew I had made progress from being someone who barely passed most of my first year classes. I felt I was finally getting in the swing of things.

STEP 1 scared the living crap out of me. I knew how important it was, and my main goal was to not close any doors by my score. Granted, I pretty much knew that I didn’t want to do any of the hyper-competitive specialties, like orthopedics, ENT, plastic surgery, dematology, vascular surgery, radiation oncology, radiology, or neurosurgery; these have averages of 240 or above. I honestly just wanted to do above average, which meant 230 or above, in order to be in the top half of applicants to specialties that I was really considering. I really believe that nobody wants to be below average in life, even though come on, half of us are below average at any given thing (yay, math). Above all, like any good diligent little med student, I just wanted to do well. And true to my own philosophy, I wanted to do as well as I could.

I got a 234 on one of the assessments about 2 weeks before the exam, that provided a rough predictor of my status. I should have done more over the course of time, but I decided extra studying for a day was worth more than an assessment. I had some very intense studying for the month leading up to the exam, and was studying fairly intensely for the 5 months before that month. I used mostly only STEP 1 resources even in studying for my classes, so I was essentially preparing for STEP 1 my entire second year. After crushing all of the UWorld Qbank in 8 days after that assessment, I felt on top of the world and ready to kill this test. The first two years of school had really shaken a lot of my confidence, especially academically. Med school has a way of doing that. But for the first time in awhile, I actually felt kind of good about it. I’m not a person that’s known for lacking confidence, but STEP 1 just had a way of getting to me, especially in trying to remember so many details that kept not sticking.

I honestly thought somewhere in the 230-245 range was a realistic assessment of my ability. I had been above average on all of my NBME final exams at the end of the year, I had been near or above average in most of my classes; my campus is insanely smart, we usually have the highest or second highest STEP 1 average in the state as far as regional campuses go. Our institution as a whole usually does above average.

Then test day came. I could make a lot of excuses for what happened that day, and I’m not sure what exactly happened. My brother got attacked by a case of food poisoning at 1AM, which the vomiting caused me to lose out on 2 hours of sleep, bringing my total somewhere around 4 or 5 that night before. So that sucked, and there was nothing I or he could do about that. But I still felt wired when I got to the test center, only to realize that I’m an idiot and printed out the thing that said “This is not your scheduling permit” as my scheduling permit. So that was another 20 minutes of figuring that out. Then I started the exam more than an hour and a half after my scheduled start time (I was the last of the exam takers to start that day) because they were so slow at getting us in the room. I digress, because fighting through and dealing with the things that life throws at you is an essential skill for anyone, let alone a future physician. Coming out of that exam is like coming out of a warzone, you have no way to judge how you did. I didn’t exactly feel great. I mismanaged my time on one or two of the sections, I second-guessed myself sometimes, and just thought it was difficult. Then again, I’d felt that way during a Qbank block, only to find out I got 90%+ of the questions right, or on an NBME exam and ended up a standard deviation above average.

So, I sat back and waited. Then, Wednesday morning, the score email was sent out. I’d had anxiety about it for weeks, and I ducked out of my anesthesia rotation to check it, with the blessing of my resident, of course. After fervently refreshing the page for 20 minutes, because of course it was broken/slow, I got to download the report.


The hammer dropped: 226. 


I’d imagine plenty of students would be happy with that, but I was shell-shocked for the rest of that day. I was below average. That was the part that stuck me the hardest. My emotions completely got the best of me, and I just kind of shut down. After all that preparation and how all of my predictive indicators had been, what happened? Did I just flop? I take a lot of pride in performing when it matters, when it’s “gametime” if you will. I had confidence I would perform well on the one 8-hour period that was the summary of 2 years of my life. It hurt. Again, maybe that was me being full of myself, but I was just disappointed that I felt I didn’t perform to my potential.

The next stage was external anger. Anger that one single day would overshadow and represent 2 years of work. That some stupid test had such a big influence on my life. That how could I have screwed up after doing so well on standardized tests in the past. If I was in the top 5% of all people who took the MCAT, how could I be this low now? How was it fair that since everyone gets different questions, I might have gotten screwed by getting random questions about things I knew less, whereas I could have done a lot better with someone else’s exam? How could it be fair to not even look at applicants for certain specialties below a certain score? Why do we even do these dumb standardized tests when they provide little indication of real clinical ability, which is what actually matters?

Then came the internal anger. Why did I suck? Why did I even choose medicine? Why should I even continue with this? Why do I do this to myself? How did I manage to screw up in the clutch, when it really matters? This one test is 10 times more important than all the rest of the tests I had taken in medical school combined. Do I even know how to study? Am I going to suck as a doctor? What if I wanted to do something competitive? Will I even be able to do what I want?

I had a lot of immature and childish thoughts in that 24 hours, all about things I couldn’t control or could no longer control. It sucked. It still sucks. But that initial feeling is wearing off, and it’s being replaced with the feeling of no longer crying over spilled milk.

I’ve come to grips with my score, especially with realizing it really isn’t that bad. And in the end, if I get a residency I’m happy with in a specialty I want, I’ll be fine. I just might have to do a little bit of extra work, especially considering the specialties I’m most interested in: general surgery, internal medicine, and emergency medicine, have an average of about 230. I’ll have to go do some research thing or other, we’ll see. I can accept there’s nothing I can do about it now, and regardless of my feelings towards one single day having such a big impact on my life, that’s the way things are. Nothing I can do will change that. I don’t think that’s apathy per se, it’s being realistic and accepting the world for what it is. I’ve had the Serenity Prayer go through my head a million times:

“God, please grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

It’s definitely killed my motivation to study for the moment, and will definitely rock me for my studying for STEP 2 which is coming up within the next year or so. It will also make me question everything I do in school. It’s going to be a slow road back to academic confidence. Wow, even typing that sounded a bit dramatic. It’s not like I got below a 200 or anything, but my mind has a way of magnifying the slightest deficiency into a mountain. I strongly believe that’s a trait that helps people like me survive and excel in medicine, but also carries as big a negative as a positive. I’ve maintained a bit of perspective and realized…my score isn’t bad. At all. I’m still going to be able to do what I want. Things are going to turn out okay, I’ll be damned if I’m going to let one test dictate or control my life. I’m going to be back up on my feet and get my school confidence back…it just might take awhile. But when I do, I’m going to come back stronger than ever. This isn’t how I expected to end this post, because as I’m sure you could tell, it had a bit of a depressing tone. Putting all these thoughts down lit a little bit of a fire within me. With time, that’s only going to get bigger. I’m going to smash every obstacle in my way and continue that road to being the best person and physician I can be. STEP 1 isn’t where my story ends. To the rest of my medical career and future exams, I have one thing to say:

Come at me, bro.



I’m going to start linking a song with every post I make, because I love music and like sharing it with people. So here you go, music video complete with weird hip thrusting:

Lean on – Major Lazer & DJ Snake Feat. Mo

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