The only clocks in the room were the digital, silent type, but still I heard it.
The first hurdle to becoming a board-certified physician was looming as the ticking in my head grew louder.
It is now the summer following my second year of medical school at the University of Minnesota, and students across the country have just taken the eight-hour-long, 308-question United States Medical Licensing Examination Step 1. Here I outline some of my experiences preparing for and taking Step 1.
The Importance of Step 1
Residency programs use Step 1 scores when deciding who to invite to interview at their program and hospitals. An individual’s score is as important as any other factor involved in this decision, be it research, extracurriculars or clinical grades. The weight of this didn’t fully settle onto my already bowed shoulders until well into the six-week-long study period. How hard I worked then, how well I did on this multiple-choice assessment, may change what I end up doing on a day-to-day basis for the rest of my life. Even if the difference between an average and a good score doesn’t change the specialty I choose, it could certainly change the location of my residency, the city I will live in for three-plus years following medical school. Silly mistakes and poorly-studied material would have more influence on the course of my life than ever before, as would the lucky guesses and extra nights spent committing information to memory. Taking time away from studying became more stressful than the studying itself.
The Good Ol’ Days
A calendar year ago was the last built-in summer break of our academic lives. This was also when we started hearing murmurs about the Step 1 exam. Extra-institutional board resources started to pop-up in conversation. Many students bought Pathoma, a succinct review of all of the pathology we would study in our second year, written by Dr. Husain Sattar from the University of Chicago. Along with First Aid and the USMLE World Question bank, Pathoma is part of the Holy Trinity of Step 1 studying, and a good book to have before getting into the second year organ systems courses, which are the real meat of medical school, so to speak.
That year started with the proverbial pedal pressed down to the underlying metal. Time for kidding around was quickly evaporating. Heart and lungs first. Blood and guts second. Brains and nerves third. Winter break. Exhale.
I liken winter break of second year to the warming-up before an intense sporting event. Nothing had really started yet in terms of Step 1 study. But some students were doing a few wind sprints. Others were casually stretching out their hamstrings and talking to a coach. Some were getting a long drink of water and watching others warm-up. By winter break, Step 1 was on the mind.
And then we were back, covering renal, endocrine and reproductive health. By this point many were using Pathoma regularly, as well as First Aid, the Bible of Step 1 studying (or whatever Holy book you prefer). Everything we need to know is at least mentioned in this text, but maybe not to the depth we need to know it. It is a colorful book, dense with information and helpful mnemonics. It’s really a joy to read, if it didn’t have such an ominous association, because by the time you are going through and understanding First Aid, the End of Days is nigh.
Outside our windows, winter gave way to spring, but inside it felt more like fall transitioning to the dark days of the coldest season. The final unit, Human Health and Disease 5, was upon us. In each of the previous four units, organ systems were paired that interact with each other, or have overlapping learning points. Blood flows from the heart to the lungs to receive oxygen, before being pumped into the rest of the system. The brain is obviously the focal point of psychiatric illness, and is made of the same general tissue as peripheral sensory nerves. Diabetes is an endocrine illness that often manifests as kidney disease. This fifth and final unit, however, was more of a grab bag of information left to learn. We study the eyes and skin and bones and facial cavities and systemic autoimmune diseases all at once. But it also signaled the final push. We had passed the final examinations meant to test our knowledge of the major organs within the body. We were getting close.
During this final unit, time was also “officially” spent preparing for the Step 1 exam, whether that meant reviewing old topics or preparing resources and a study schedule. Over spring “break” the university provided a first attempt at a real practice Step 1 test … a baptism by fire, and one that “encourages” students to “prepare a bit more” before being baptized again. In other words, many of us didn’t do well.
A conflicted energy swirled out with us as we opened the doors after the last final exam of our second year. The fifth unit was over and we were done with the classroom portion of our medical education. It was both a satisfying and frightening realization. We were left with between four and eight weeks to review the information we learned in the first two years of medical school. All of the information. It was a grind, but sitting at a desk in isolation memorizing facts was something we had all become good at.
Questions on the Step 1 are in vignette form, and often are written in such a way as to make a test-taker have to know several layers of detail to get to an answer. Instead of asking, “What is this disease?” they ask, “Based on this image of a biopsy from this organ, what side effects would you need to consider when administering the proper treatment?” This is much closer to the thought required of a physician in the actual clinic than a one-liner followed by single word answers. Instead of passively reading text or recalling individual facts with flashcards, practicing with well-written questions coaxes the brain into navigating old connections and stumbling across new ones in the process. That said, it can also be unbelievably frustrating to understand the first two or three levels of a question, only to forget a final piece that will get you to an answer. Seems to me there should be some partial credit on those ones.
Another element of difficulty they’ve included is that the test doesn’t have different portions categorized by organ systems or themes, so anything is fair game at anytime. A question about an old man with chest pain is followed by a question about a young girl with a sore throat, which is followed by a question about the steps in a metabolic pathway. The mind must stay wide open, as well as able to follow even the trickle of an idea to its microscopic conclusion.
During the final week of preparation, recognition and understanding were at all-time highs, as were material-load and urgency. All that was left was to try and maintain what had been learned the previous five weeks. It was a delicate balancing act, trying to add a few more bricks on top while making sure the base didn’t start to crumble. There was also an element of gambling: what will be on my test specifically? Should I make sure I have the side effects of all of these antipsychotics down pat? Or would that time, and memory space, be better used cramming in these lysosomal storage disorders? There was no right answer, and in the end, as long as you kept studying and stayed relatively healthy, it was a success.
The day before my exam, I had only one cup of coffee, which was perhaps a quarter of my daily intake toward the end there. I exercised, studied until 5 p.m. or so, and closed my First Aid. A somber last supper with my girlfriend followed. As I bid farewell, a single tear traced a fresh path down my ink-stained cheek. All would be over soon.
I felt good the morning of. Somehow, I had stayed focused and on-schedule during my study period. The practice tests I took hinted that I was prepared to do as well as I hoped on the real thing. I was relatively well rested, had packed sufficient calories and caffeine to get me through the eight hours of exam, my lucky rabbit’s foot was around my neck and my lucky socks were on my feet. Nothing was going to faze me.
Right away I had to take off the rabbit’s foot because the chain it was on set off the facility’s metal detector. Not ideal, but I still had my socks, and the power of a rabbit’s foot can certainly travel through the thin aluminum of a locker, around a corner and under the testing door. I was still at nearly full strength. After an ID check, a few fingerprints and a signature, I was sitting at the computer, staring at the first of over 300 questions.
Two questions later was one that included audible heart sounds. Unfortunately, those sounds weren’t coming through my headphones. This was the one type of question I wasn’t prepared for: how do I stay calm through a software malfunction? After a moment of troubleshooting, which included looking around frantically, replugging in my headphones and toggling the volume up and down, I raised my hand. The test administrator promptly helped shut down my station and relocate me to a nearby desk, which happened to be the one labeled number 15, my lucky number. That was a very good sign at a crucial moment.
I had lost almost two minutes during the fracas and was rushed toward the end of that first section. But I figured there were going to be much more difficult problems to work through as a physician, and that perhaps an audio malfunction was just the part of the exam meant to test patience and resolve under pressure. Well, that’s what I told myself so that I didn’t punch something. The rest of the test was relatively unremarkable, aside from its length and difficulty.
I feel more positively about the Step 1 experience than I thought I would. Back in the winter days of second year, I knew the exam was something I had to get through, and that it was very difficult for a variety of reasons. But I didn’t know then what it would actually look like for me to organize a giant body of information and systematically wrap my arms around it. Moving forward, I am more prepared and confident in my ability to build something large using small steps. It remains to be seen how much of the material I will continue to use regularly, and how much will be repackaged as a vague intuition I rely upon when out of conscious ideas. But for the time being, it feels important to have solidified the concepts and essential facts from the first two years of my training, even if the strange names of all of the drugs I just memorized change before I can legally prescribe them.
Now it is time to let out the stale breath I took in long ago, take apart the makeshift standing desk I constructed out of cardboard boxes, burn a few piles of notes and get ready to interact with the real world. The time for studying the principles behind the actions is finally over. Now it is time to see what health care providers actually do.