The ThugMed Guide to USMLE Step 1

by thethug on March 25, 2011

It’s been a long time since we posted anything but to sum up our lives in the one phrase: We’re still living the dream.

I, N-Thug, have decided to pursue a career in the US and so I had to sit the dreaded USMLE Step 1 exam.  Having now sat the exam and received my score we present The Thug Guide to USMLE Step 1.

First thing I have to say to all you players out there, is that you have to be 100% committed to taking this exam.  Many people have semi-started studying for the exam before, only to lose interest a month later.  When you start studying for this exam in earnest, you will have to sacrifice certain things in your life – sleep, TV, Xbox, poppin bottles in da club, etc. I will admit, I even sacrificed the gym the last 10 days. If you need inspiration refer to the earlier Diddy and Wayne video.  People will complain:  “I don’t want medicine to take over my life” “It’s Friday night, I don’t want to study.” I reply: “Time to separate the boys from the men.”

Be honest with yourself as to what your goal score is. Personally, the thug mentality is that you should aim for perfection.  Trolling the USMLE forums, apparently the maximum score is 300. I am sure that if you were to actually achieve this you are immediately awarded the Nobel Prize for Medicine. Looking at the NRMP Charting Outcomes in the Match ( the only hard evidence that there is there are people who score above 260, but they are few and far between. According to my score report issued by the administrators of the exam, the mean (for US medical graduates) is 221 with a SD of +/- 24. The true mean, which includes foreign medical graduates (FMGs) will be lower. Disregard the 2 digit score people talk about, no one cares and it is not a percentile. Unfortunately , NBME/ECFMG do not give you a percentile because apparently the distribution of scores is not a perfect bell curve. To set a goal for yourself, decide what specialty you want and then beat the US medical graduate mean of those who successfully matched (this data is all available from the above link). Or if you’re a baller just beat the standard deviation (currently 221 + 25 = 245).

Before you read any further, I got a 254, so what I did works.

Only get:

First Aid for Step 1 (FA)

Rapid Review Pathology

Goljan Audio Lectures

USMLE World Step 1 subscription (UW)

(I also got HY Cell and Molecular Biology, HY Behavioral Science, HY Neuroanatomy, BRS Physiology, RR Biochemistry, Clinical Microbiology Made Ridiculously Simple, Lange Review of Medical Micriobiology and Immunology. I read through these over a period of 6 weeks before I really started studying and when I first started doing questions I realised that I hadn’t learnt anything at all from these books and it is incredibly time consuming. I definitely do not recommend doing this, even if you feel you have very little grounding in basic sciences)


1) Take an NBME practice test in timed mode as if it were the real thing. This is purely to shock you into realising how little you know and how much you have to study. It will provide the motivation to actually study harder than you ever have before.  I recommend NBME  4 because you want to save NBME 6 and 7 for later.

2) Do 46 random questions in random and unused mode from UW. Do it in random and timed mode to prepare you for timing of the exams. Do not feel disheartened if you are getting percentages in the 40’s and 50’s. This is time to learn and it is the best way. When you go through your answers, open FA and read the section regarding the topic addressed in the question first. If in order to answer the question you need to expand on the FA material using the explanation given by UW, annotate your FA. As you can imagine, this means that in order to answer and go through all the answers it takes roughly 4 hours. However, this helps you keep the pace and will you get to know the content in FA.

3) After you have done your 46 questions you now read Rapid Review Pathology (RR). Once you finish reading a chapter in RR (eg – cardiology), then read the appropriate chapter in FA. It will take you a few days to finish a chapter in RR and then another few days to finish the chapter in FA.

4) Anytime when you are not studying from either UW or RR or FA you should have headphones on and be listening to the appropriate chapter on Goljan Audio. Whether you are cooking, going to the supermarket or lying in bed about to go to sleep. This is the easiest type of studying, but you need to pay attention but Goljan explains things better than any other lecturer you have had – ever.

5) Once you have done a thorough pass through RR, put it down and don’t pick it up again. But start from the beginning with FA. FA obviously has sections that RR doesn’t  (Biochemistry, Microbiology, etc) and you cover these just using FA and UW. Once you have finished RR you should go through FA two more times. This is separate from your reading of FA while doing UW questions.

6) FINISH UW. This is the most important study tool out there. Once you have finished all the questions, go through the questions you got wrong. Some people like to use the UW percentage calculator to approximate there Step 1 score. UW average * 2.3 + 84 = Step 1 score. This is a rough estimate, however the best estimate are the NBME’s.

7) Once you are half way through UW, take NBME 5 and see where you’re at. Increase your studying accordingly.

8 ) One month away from taking the real thing, take NBME 6. Pay for the extended feedback on the exam so you can find out where your weaknesses are. Also go through your wrong answers and find the right answer, the feedback does not give you the right answer. If you type to question stem into google, you will find many people like yourself searching for the answer.

9) Two weeks away from the real thing take NBME 7. This is the moment of truth. If you are not happy with the prediction it gives you, delay your exam and continue studying. Go through the questions you got wrong on NBME 7. Everybody gets 2 to 3 questions on the real Step 1 that are IDENTICAL to either NBME 6 or 7 and therefore these should be free points.

10) Take the exam.

Exam Day

There are 7 blocks. Do the first two blocks back to back. You are fresh, excited and don’t need to pee. From now on take 2 – 3 minutes after every block to go to the bathroom, empty your bladder, clear your head from the last block and take a few sips of water. After the fourth block take 20 to 25 minutes for lunch. Eat light so that you have minimal postprandial tiredness.

With regard to timing, the question stems are similar in length to UW. If you do not have an issue with timing when doing your UW blocks then timing will not be an issue on UW.

Further Advice

Use the Goljan audio as your “relax” time. It is studying that requires very little effort and you should go through it twice, if not more.

The format, timing, layout, etc of UW is IDENTICAL to the real exam. This means that when you come to take the exam, it’s as if you are just doing another block from UW.

Remove the spine from your UW and put it in a binder. This will give you more writing space in the margins and allow to add pages if need be.

You need to know everything in FA. This includes memorising all the pharyngeal clefts and their derivates, this includes all the cycles and pathways of biochemistry. DO NOT IGNORE THIS.  Knowing these sort of details is the difference between getting an average score and a great score. When you start, these sections will make no sense to you and you will feel as if you will never understand it. You have to work through this and with time and practice you will understand it. Also, when I say memorise FA, I don’t mean that you have to recite the book from memory. However, you should be comfortable with everything in the book. You know when you are at this stage when you no longer use the index or the table of contents when looking something up, because you know its exact location in the book. No one expects you to memorise every side effect of every drug listed in FA, especially since there is so much overlap. However, if a side effect is mentioned in UW, then you definitely have to remember that one.

Your NBME practice test score is the most accurate predictor of what you will get. When I started I scored 209 (NBME 4). Half way through I scored 229 (NBME 5). When I had done 1500 questions from UW I scored 229 again (NBME 6). At this point I realised that I had to memorise Biochemistry and Embryology. Two weeks away from the exam I scored 249 (NBME 7). On the real thing – 254. I truly believe that what kept improving my score was going over FA again and again while doing questions. It will eventually start to make sense.

People ask all the time: How long does all this studying take? It took me 3 months of serious 5-6 hour/day studying. (Serious studying means actual high yield no interruptions, a lot of people say they study 8 – 10 hours but they are factoring in little breaks, browsing the internet, etc). That being said, the real answer is that it doesn’t matter how long it takes. You can’t retake this exam, and it is the single most important factor in determining your residency. You study until you get the score you want. This could take a couple of months or it could take a year. In the end nothing matters other than your score.

Go big or go home.

ThugMed 4 Life


ThugMed is growing… Join Us

by thethug on June 28, 2010

People all over the world are using ThugMed -34 countries to be exact.

We’re looking for new people to join our team and take ThugMed to the next level. If you’re interested just drop us an email through the contact page or email

Join us.

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A Message from Lil Wayne

by thethug on April 2, 2010

This is the second time Lil Wayne has been featured on ThugMed. Right now Lil Wayne is in Jail, but today he wrote:

“Love. Live. Life. Proceed. Progress. That’s who I am and who I’ll always be. You see, we’re all living on borrowed time, so I’m not worried about this situation. Life happens quick. The more time you spend contemplating what you should have done…you lose valuable time planning what you can and will do. Trying to tear down the past prohibits you from building up your future.”

Although Lil Wayne may not be a typical role model for medical student/ doctors, imagine if a professor said: “Love. Live. Life. Proceed. Progress” – they are strong words.

ThugMed is getting a lot of email right now from people all over the world studying for exams, good luck to you all. I just hope you are all having fun while studying. That may sound crazy, but it’s true, last year when N-Thug and I were working towards final exams, we chilled, partied and studied – it was an amazing time. 



they don’t teach this at medical school

by thethug on December 5, 2009

spreading happiness…. they don’t teach this in medical school. Emotions are contagious and patients are very receptive to doctors’ emotions. I just got off a 14 hour surgical on-call, I swear my job was made easier today by trying to instill a sense of positivity and happiness in all my patient interactions.

You may read this and think I’m totally crazy – but I challenge you to try it. If you don’t believe me, take is from this guy:


Ace of Spades

by thethug on November 30, 2009

To be the best, you gotta learn from the best.

Today I drew inspiration from Armand de Brignac aka The Ace of Spades.

3 values; exclusivity, tradition, excellence. Add these to a career in medicine if you wanna be the best.


OnExamination vs. Pastest for UK Medical Finals

by thethug on October 27, 2009

Picking a question bank for UK Medical Finals isn’t an easy task. There a many options available, but the two most popular are OnExamination and Pastest. I used both of these sites for studying, but it’s time for a hardcore review. I could not find a good comparison of OnExamination vs. Pastest, so here it goes…


Overview: At £44.03 for 3 months it’s the more expensive option (as discount is available if you’re a BMA member). OnExamination offers over 4000 questions in a variety of styles e.g EMQs (extended multiple choice), MCQs and short answer questions. In total, OnExamination has 800 more questions than Pastest.

User Interface: OnExamination has a user intuitive interface which allows questions to be selected by speciality or randomly. I didn’t notice any faults with the system and it ran smoothly. One minor point is that the user is not able to search for specific questions e.g if I wanted to do some questions on warfarin, there is no “question search” feature.

Questions: This is OnExamination’s biggest weakness. The questions are very repetitive and often test fact recall rather than clinical reasoning. Considering most medical finals do not test fact-recall, many of the questions did not seem applicable. UK medical schools are using more and more Extended Matching Questions (EMQs) in exams, OnExamination has 2000 of these. There was a mixture of quality with these EMQs, some tested facts, while others involved some clinical reasoning.

There is a big question quality discrepancy between specialities, for example, the cardiology section is much more challenging than the general surgery section. Hard questions are a great way to learn, but the cardiology section was too advanced.

The quality of the question explanations is apauling with OnExamination. The explanations were short, poorly structured and had spelling errors. The explanations didn’t address the questions, they were often facts regarding the conditions. However, my biggest disapointment came when I noticed some of the explanations had been copied directly from Wikipedia. Don’t get me wrong, I love Wikipedia, but a ‘copy pasted’ article from wikipedia as an explanation to a question is unacceptable.

The poor quality of explanations is the main reason why I would not recommend OnExamination to any student revising for medical finals.

Value for Money: £44.03 may seem a little expensive compared with Pastest, it is resonable considering there are almost 4000 questions. If you did every single question, the site might be worth the money, but most students only get through 1000-2000.


Overview: £27.39 for 6 Months. Over 3200 questions and 91 OSCE scenarios. Pastest is an established company within medical revision. They have many books available and the online question bank reflects their maturity as a organisation.

User Interface: This is Pastest’s weakest area. They recently released a new interface which improves matters slightly, but it isn’t as flawless as OnExamination’s. At times Pastest’s website lacks stability e.g it says “an error occured, please check back later”. This only happened 3-4 times for about 10 minutes in the months that I was using the site.

The best part about Pastest’s user interface is the “search” function. This allows a user to search for specific questions using a keyword search. I found this very useful if I studied an obscure topic and wanted to find some questions related to it or if I wanted to find a question I had done previously.

Questions: The questions on Pastest are better than OnExmination’s. Pastest’s questions are mostly at the level appropriate for a final year medical student. The explanations are short yet give the necessary information (there are occasional spelling mistakes). I used these explanations are part of my revision on multiple occasions. Pastest seems to understand what medical students are supposed to know. In contrast OnExamination sometimes felt like the questions were not based on medical school learning outcomes.

Pastest also features 91 OSCE scenarios. The site presents a scenario and you can think about it before looking at an explanation. The explanations for these scenarios are excellent. The scenarios are clinically relevant and are very helpful for revision (although you will still need a dedicated OSCE book).

There are some additional multi-media features such as eLectures or audio revision guides, however, I didn’t use these.

Pastest isn’t perfect. There are almost 900 True/False questions which are not useful, especially due to the wording e.g “it is not uncommon for..” – a double negation makes it uncessarily complicated. Additionally, the paediatric section is weak, after having completed all of the paediatric questions I didn’t feel confident. Therefore, you’ll need another resource for paediatric questions.

Value for Money: £27.39 is an amazing deal for 6 months, especially because it includes the 91 OSCE scenarios.

ThugMed’s Recommendation: Pastest is the overall winner. Great value for money,  excellent search function and good explanations. I wouldn’t hesitate for a second to recommend Pastest as the question bank of choice for UK Medical Finals.

The main reason why I signed up to OnExamination also was because I felt like I should do as many questions as possible. The closer to exams I got, I realised this approach wasn’t necessary, stick to one question bank (hint: use Pastest). OnExamination is expensive and has low quality explanations – avoid it.

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Video Blog 005 – Don’t Buy Book Ever Again

by thethug on October 13, 2009

We’ve just signed up to Facebook (search for Thugmed) and Twitter (thugmed)! See you there.


Video Blog 004 – Being A Doctor Begins…

by thethug on August 18, 2009


Video Blog 003 – Final Exams

by thethug on June 6, 2009


Video Blog 002 – Study Techniques

by thethug on May 24, 2009

This is the ultimate test!