USMLE Step 1 - 274 Experience

USMLE Step 1 Experience – 274

Hi guys I am a relatively older graduate. This is my experience of doing USMLE Step 1 after doing residency of 3 years in my home country.

Medical School Graduation: March 2013

Residency Graduation: May 2017

I was a above average student in my medical school but that did not matter as I took my USMLE after such a long gap that I had forgotten everything of medical college & things like Urea Cycle seemed like ancient fossils to me. I started almost fresh when i began USMLE prep. I started my USMLE prep in between residency and I had done Kaplan Lecture Notes for USMLE Step 1 along with latest First Aid USMLE Step 1 before i finished residency. After residency was over i studied for 4 months before giving the test.

I had done Pathology residency so pathology which is a major chunk of USMLE was easy for me. However, the difficult questions in my exam were not of Pathology by of Anatomy and Behavioural Science. Fortunately i had done all NBMEs before giving the test so I was aware that these 2 subjects had to be studied more in depth. Below i will explain how i did those 2 subjects.

So let’s start out.. First thing’s first and that is First Aid USMLE Step 1.. It is a great resource.. However it is more like an Index than an actual book. What i mean is every word in the book is important. Just rote memorization of the book will not work. You have to understand each and every point in the book. If there is even one small line in a diagram then you have to understand the topic before memorizing. For example:

There is a topic of ECL cell stimulating Parietal Cells via Histamine. Now this might seem like an obscure minutae but it is actually very important. For example, a question could be framed using the history of epigastric pain and history of smoking (risk factor for peptic ulcer). Then they may say that person was given a drug which caused Gynecomastia. The drug blocks the substance which is produced from which of the following cells. Then options could be the labelling of the following diagram below. Now the way to answer this is multiple steps. First step —> Understand which disease patient has —> That can be done from history give and risk factors given —> Then you have to understand which drug the patient is on —> He has been given a pill which caused gynecomastia —> Out of the Peptic Ulcer drugs the one which most commonly causes this is Cimetidine —> Now you must know the mechanism of action of Cimetidine is H2 receptor blocker —> So drug is blocking Histamine —> You now know the substance —> Last step is to know the cell which made it —-> Cell is ECL cells –> That is the answer. Understood how it works ? Its multi-step reasoning ? Read on in the experience and i will reveal more tricks and tips to score well on the test below.

USMLE Gastric Acid Secretion - Parietal Cells - ECL Cells - Histamine

USMLE Gastric Acid Secretion – Parietal Cells – ECL Cells – Histamine

Now you see that while this image is quite daunting but it must be understood well in order to score well on the test. Brute force memorization just will not work. The way to learn FA is simple. Whenever you are doing FA.. and dont understand XYZ topic then the simple way to find out more is to type into google:

XYZ USMLE.. Like in this case it would be Enterochromaffin Cells USMLE.

It is important to put USMLE at the simply searching Enterochromaffin Cells will lead you to pages which have non-specific information about it. Like it may have an esoteric research paper of ECL cells which talks about the anthropology of the cells and how similar cells are also available in primates and monkeys and in humans. This is useless information as this does not pertain to our studies.

So, TIP 1: Always google every small part of First Aid USMLE which you dont understand as it may be high yield. In fact a lot of the topics i was tested on..they were not given anywhere, but when I searched them online then i found a lot of sites where entire USMLE related information is given of a topic. Don’t look at the forum posts results.. Like i used USMLE Forums and SDN etc but there sometimes the students are discussing a topic and they themselves also dont know the exact topic, so instead of forums rely on articles written in sites.. there are many such sites, just google and i am sure you will find the information. So, long story short, dont rely on First Aid USMLE blindly, instead do google search of topic with USMLE in the search string. Like “Enterochromaffin Cell USMLE” instead of just “Enterochromaffin Cell” and use First Aid as Index.. its not final book.. it just gives you topics but if you search properly you will get many topics noone will know of.

Now, back to my journey, I started doing this FA with google search + UW + Fundamentals of Pathology (Pathoma) after my residency was over. It took me 2 months to do that. Please keep in mind that i had already done Kaplan Lecture Notes for USMLE Step 1 and 1 time memorization of First Aid USMLE Step 1. So i was done with that in 2 months.

After this I took 2 NBMEs back to back every Saturday & Tuesday. So every week i was doing 4 NBMEs. 2 NBMEs each on both the days I mentioned. The reason i did it this way is that the real exam is 7 blocks long, but NBME is only 4 blocks long. This is a discrepancy. Because when you will give long exam you will realise that last 2 block is when the mind fatigues out. It is inevitable, there will always be mild deterioration of execution capacity in the last 2 blocks. One of the reasons i thing some people get worse score in real exam as compared to NBME is that they have given 4 block test with fresh mind but in real exam their performance deteriorates a lot in the last couple blocks and the NBME score no longer remains predictive because of the deterioration of functioning. I wanted to make sure this doesn’t happen to me, so i gave 2 NBME back to back. I calculated my score as average of the 2 NBMEs. So lets say i got 245 and 252.. i would calculate my score as 248.5 In this way i gave 2 NBME on aforementioned days of the week and remainder days I would meticulously go over the NBME explanations. This helped me a lot as i used the NBMEs as a learning tool as well as an assessment tool. I identified that i was very weak in Anatomy and Behavioural Science. This was very helpful as in my real test these 2 topics were asked in depth. if i had not done NBMEs like this I would never have been able to diagnose and treat my 2 USMLE ailments: i.e. Anatomy & Behavioural Science.


To improve anatomy i did 2 books. Both with their pros and cons:

High Yield Gross Anatomy:

This is a great book with a lot of useful information especially on Clinical application of Anatomy. That is a part which is missing in many places. While the information related to Anatomy is good in UW, it is terrible as far as Kaplan USMLE Step 1 Lecture Notes is concerned. Also the information in First Aid USMLE is average at best. So i recommend looking into High Yield Gross Anatomy for the clinical aspect of Anatomy. Things like which intercostal space to do thoracocentesis, where to do Liver Biopsy, which layers are passed through while doing it. Such topics amongst many others are not given elsewhere.

BRS Gross Anatomy

BRS Gross Anatomy was an amazing book not for it’s text but for 550 questions in it. There is a lot of amazing material there about basic gross anatomy. Also they have MRIs and CTs of weird angles not given elsewhere. Things like Carpal Tunnel MRI with the tendons in there and identification of the same is a very high yield topic. Even in my wildest dreams i would not have been able to identify stuff on my real exam had it not been for this great book. The questions are pure gold. Also there is a test at the end of the book which is great and worth doing. I got a lot of high yield info from here.

Guys you wont believe that in entire medical college education i used to suck in Anatomy. I got fail score on my first NBME i took online for Anatomy. But you wont believe that in the real exam i got an amazing score in Anatomy. I got a star at the right side on my test. I was very worried about this subject but gradually as i went one by one through the NBMEs I improved from left side bar in assessment (i.e. fail level in assessment) i went to right side (meaning very above average). Thats the power of using NBME as a learning source i did each and every NBME and also did the wrong questions before exam. I had done them all with explanations as real power of NBME lies in the explanations. You cannot expect to score well without doing it as learning source in addition to assessment source. The key lies in identifying mistakes in NBME and improving those subjects. For that you have to dissect NBME inside out. Not just do test and leave but do entire explanation. Do each and every option and the right answer as well as wrong answer you must understand what is going on, why option which is wrong is wrong. Because in test you may not get the exact question but there is high chance you will get question based on one of the incorrect options. I learnt a ton from incorrect options and believe me that is what got me to 270+

Behavioural Science:

This is achilles heal of all IMGs, and the way to mitigate this issue is to do 3 books in addition to Kaplan and FA and UW. These 3 books are:

BRS Behavioral Science


This is a great book and like all BRS Series, it also has tons of questions. 700 to be specific. This amazingly large number of questions is what makes this a great resource. I did each and every question and dissected the subject inside out. In the real USMLE test.. This paid off as i had a lot of topics in the book which i hadn’t seen anywhere else. Also I recommend doing the NBME Behavioural Science questions separately as they are very high yield and you will get a decent amount of topics repeated if you do the ┬áNBME Behavioural Science questions with explanations.

High Yield Behavioural Science

This book is also decent. I did both BRS and HY. Many things in HY were also in BRS. But also many things were new. So i recommend you have a look at this if you are short of time and can’t do BRS.

– Kaplan Medical USMLE Medical Ethics: The 100 Cases You Are Most Likely to See on the Exam (Kaplan USMLE)

This book is well known. It has high quality information which can be covered in 1 day if you start from morning and do till evening. I recommend this for sure.

So basically i did UW + FA + Pathoma for first 2 months. Then i did NBME 4 test per week on 2 days along with indepth explanations of each for rest of the NBMEs. I did this for 4 weeks and finished all the NBMEs before last month of exam.

In last month, I went over UW, FA, Anatomy, Behavioral Science and NBME test wrong questions. After doing all this i was sure i would get good score.

Exam experience:

I packed a ton of food. Red Bull, sandwiches, peanuts, etc. The exam was lengthy and blocks were quite long for me. I felt i was alert throughout the test. I felt the test was much harder than NBME test but that’s how everyone feels. After 3 long weeks of sleepless nights.. finally got the score. It was like a dream come true for me.

I wish you all the best. If you have queries, please post below and will try to help.

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October 28, 2017