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

{ 7 comments… read them below or add one }

Love 03.26.11 at 3:51 pm

Love it! ThugMed 4 Life 😀
Keep it comin! Homie, you the bestest!

bojangles 03.27.11 at 2:27 pm

Thanks for this! I’m studying in a similar manner. I started off with a 209 on my first NBME, so you give me a lot of hope 🙂 I also began my studying by reading several supplemental books, though I disagree with you about Clinical Micro Made RS — the charts are gold, especially regarding exotoxins. At least for me.

mr305 10.02.11 at 7:05 pm

Hey, just wondering if you think doing the Kaplan Videos is a waste of time? I know the Kaplan Qbank is not recommended, as UWorld is better. Let me know, cheers.

jay 11.02.11 at 4:02 pm

How many hours a day did you study and how many weeks did it take you to prepare? can you give me a more detailed outline please>??

fr 11.24.11 at 10:30 pm

Hey, thanks for your post. How many hours of sleep did you get every night?

smoky bandit 11.26.11 at 4:57 pm

Go big or go home!

N 03.19.13 at 12:22 pm

“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.”

What book is this referring to?

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