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From USMLE Step 1 226 to Step 2CK 260


Warning: Do You Know What You’re Doing With the Last 2 Weeks Before Your USMLE Step 1?



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by Alec in Plan

If studying for the USMLE Step 1 is like running a marathon, the last 2 weeks are the final sprint.  A lot of what will determine your final score has already been set, but there are still plenty of extra points to be won if you play your cards right.

In general, with 1-2 weeks to go your goal should be to fine-tune your approach to the actual USMLE Step 1 (don’t have a clear plan of attack?  Read on!).  My advice for standardized tests in general is to make your practice as similar to the real thing as possible.

In other words, your goal should be to walk into the test and have everything feel familiar.

You (and your classmates) probably feel like this right now:

USMLE Step 1 Medical Student Anxiet

Your goal should be to walk into the exam like this:

USMLE Step 1 Medical School Student

How you will feel after completing the steps in this article

To that end, here are 7 things I suggest:

1. Assess Where You Are Relative to Your Step 1 Goals

We all have our goal score.  For me, it was 260, for others, it might be 240, 200, or to pass.  The beauty of the USMLE Step 1 is that the only requirement is that you pass; your goal score  will depend on your own self-assessment, your temperament, and your career goals.

The best score predictors are the NBME self-assessments.  These have been scored and tabulated by the NBME and correlated with students’ scores to give you an estimate of where you stand relative to your peers, and to give you an idea of how well people with similar scores actually did on the real exam.

You can sign up for NBME self-assessments here.

Note: I do NOT recommend using the bootlegged copies floating around online.  Even though the NBME self-assessments are not perfect, the most valuable thing about these exams is their predictive value.  Each NBME form has its own unique “curve,” (e.g. on one exam, if you get 8 questions wrong it may convert to a 620, which would predict a 250 3-digit score on the USMLE; on another exam 8 wrong may predict a completely different score) which to my knowledge has not been reduplicated.  I have no idea how the bootlegged score predictor works – use it at your own peril.

If your goal score is a 240, but you score a 200, you need to be realistic and ask yourself three questions:

  1. How important is it that I attain my goal score?
  2. What score would I be satisfied with?
  3. When is the latest date I can take my exam, and would I consider pushing back my exam date?

The answers to these questions are highly personal, and I cannot answer them for you.  For me, I would have taken the test if I was predicted to have anything about a 250, but probably would have pushed back my test date had I scored significantly below that.  I probably wouldn’t have taken an entire year off if I’d scored, say, a 240, though, although I can’t say for certain, and would understand if someone did, especially if they were aiming for a highly competitive residency.  And while most people’s scores are not EXACTLY like their most recent NBME, most are at least in the ballpark – in my experience, it is rare to see someone score substantially higher (or lower) than their most recent NBME, as long as that NBME was within a week or two of taking the test.

There is no shame in preparing to take the test until you’re ready.  More than 1/3 of my Stanford class delayed taking their exam, to give themselves more time to prepare, and I knew a handful in my and other years who took an extra year off to do research/other things while also taking up to several months more time to take the test.

You only get one shot at this exam: don’t you owe it to yourself to put your best foot forward?

2. Take 1-2 Full Length Practice Tests

The USMLE Step 1 is 7 blocks total, with each block 1 hour.  Add on the 1 hour of break/instruction time, the total test will take 8 hours.

Familiarity breeds calm. Whatever you plan to do on test day, make sure you’ve done a complete dry run first to work out any last kinks.

I personally had never taken a test with so many questions before this, and had heard fatigue would be a significant issue for the last couple blocks.  As such, I took 2 full length practice tests spaced at least a week apart, to simulate what this would feel like.  One of these practice tests was back-to-back USMLE World Self-Assessments (UWSA), each of which is 4 blocks, which is actually one block extra than the real exam, which is 7 blocks.  Since fatigue is such a big part of the challenge, training myself to answer questions beyond 7 blocks helped me when the fatigue hit on the real test day.

You can combine this with estimating your score by substituting the second of the back-to-back UWSA exams with an NBME.  This is because in the experience of many, UWSAs tend to overestimate your score, and if you take an NBME after taking a 4-block exam, it is more likely to underestimate your score rather than overestimate it due to  fatigue.  Your practice exam(s) may look like this:

UWSA #1, then NBME_ (I recommend any of the NBMEs in the teens, i.e. NBME 13+); 8 blocks total

or if you want extra practice:

UWSA #1, then NBME_ (8 blocks total)

UWSA #2, then NBME_ (8 blocks total)

7 blocks (8 blocks for the USMLE Step 2 CK) is a lot of questions, especially when it feels like you have the pressure of the world on your shoulders (you don’t; take several deep breaths).  Practice a full-length test once or twice before the real exam, and that final block on test day will be much more doable.

Additionally, I tried to re-create as many of the conditions as possible for the real exam.  In other words, I tried to use the same timing as I would use for the real exam, the same snacks/lunch, and gave myself the same amount of break time as I would have (see below).  In addition, I planned to use a sleep aid (I used Tylenol PM, others use Ambien or melatonin) before the night of the exam, because I’d been so nervous before the MCAT that I slept only a couple hours, so I wanted to use it at least once before the exam so I knew what it would feel like.

Familiarity breeds calm.  The key is whatever you plan to do on test day, make sure you’ve done a complete dry run first to work out any last kinks.

3. Schedule and Take a Practice Exam at Your Prometric Test Site

This is in the same vein as the previous: familiarity breeds calm.  The goal here is to know what it’s like to go to the test site, how the traffic is, to find the testing center, to know how long it takes to check in/out, to find the bathroom, and every other little variable you might experience on your test day.  If you’re like most, you will already be pretty nervous for your exam, and so the more you can do to demystify the entire experience, the more calm you will be on test day.

Every time something happens that you didn’t expect, that anxiety increases, which can affect your concentration.

Note: as of this writing, the practice exam at the Prometric test center is only 3 blocks (150 questions) total, and the test questions are all things that you can get for free (these are known as the “Free 150” released by the USMLE).  You will NOT be seeing new information, and that’s not the point.  I recommend using your practice session to mirror how you will take your first two breaks, to get used to checking in and out, going to the restroom, etc.

Click here to schedule your practice exam at the Prometric test site.

4. Do As Many Questions As Possible

If you want to know what the test is like, there is no substitute for practice.  I tried to do as many questions as possible (at least 100-150/day), from all subjects, in test mode, and tried to approach each question the exact way that I wanted to approach it on test day.  I highly recommend using USMLE World questions for this practice, as it is the most similar to the questions you will see on your exam.

5. Map Out Your Test Day Break/Lunch Time Strategy

The more clear your plan of attack for the USMLE Step 1, the calmer you will feel, and the more mental energy you can dedicate to applying/integrating all of your hard-won knowledge. Taking a few minutes to map out a strategy can help calm you and give you a greater sense of purpose on your test day.

First of all, except to check that your headset is working, you should plan to skip the introductory tutorial for the USMLE Step 1.  What do I mean?  Before you start the exam, you will be given the opportunity to read through the instructions of how to take the test, for which you are allotted 15 minutes.  I will save you 15 minutes and say that it is virtually the same as you’ve been practicing with your USMLE World, Kaplan, or other QBank.  The only difference is that you will have a total of 45 minutes of break time, to be used in any combination you choose.

So why skip the instructions?  Because if you skip the instructions, the 15 minutes allotted for them will be added to your 45 minutes of break time, giving you a total of 60 minutes.  That essentially adds 1/3 to your break time.

Note on breaks: At the end of each block, you will be given the choice of moving on to the next section, or taking a break.  If you choose nothing, it will choose to start your break time automatically (this is to prevent you from missing an entire section because you forgot to click on “Break”).

BONUS: Top Recommendations for Best Test Day Scheduling

Support the site below to see top recommendations for how I laid out my test day blocks and breaks.

  1. 2 blocks, then 10 min break (if necessary, 3 minute “sit-down” break in front of computer in-between first two blocks)
  2. 2 blocks, then lunch break (20-30 minutes)
  3. 1 block, then 10 min break
  4. 1 block, then 10 min break
  5. 1 block, then done

This is based off the observation from both myself and others that your attention will be much stronger in the beginning, and doing two blocks back-to-back is not much of a challenge.  However, as you move on, it becomes increasingly difficult to go over questions without a break in-between.  If you feel like you need a break early on, but don’t have one scheduled, you can give yourself a short, 2-3 minute “sit-down” break, by sitting at your computer and starting a break, but without taking the time to check out and in again.

6. Actively Shore Up Last-Minute Weak Areas

No one walks into the test feeling 100% on every subject – you are bound to have things you feel stronger and weaker on.  While some people prefer to use passive methods (i.e. listening to Goljan, watching Pathoma/Doctors in Training, etc.) I never found these particularly useful.  Instead, focus on active methods for testing yourself.  These include:

  1. Using the USMLE Step 1 tutorials on this site (Table of Contents), including subjects ranging from Nernst potential to the coagulation cascade, to ion channel physiology and EKGs.  These are designed to test you actively on knowledge from First Aid/Qbanks, but in a way that is integrated and applied – exactly what you will be tested on for the USMLE (sorry, couldn’t help promoting the site’s own content!).
  2. Quizzing with a friend.  Ideally you can find someone whose strengths/weaknesses are complementary.  Go back and forth testing each other on things you’ve learned.
  3. QBank questions.  Mentioned previously – this is the best way to see if you actually are able to apply the knowledge in a test setting.

7. Embrace the Unexpected

Remember that no matter how well you prepare, there will likely be something that happens you didn’t expect.  You forget to make your lunch, you make a wrong turn, or someone else in the room has a horrible cough and you can barely hear yourself think.  Expect it.  That’s part of the fun of test day – you’ve done your best to prepare for this, but there will always be some little wrinkle that throws you for a loop.

Even if you’re lucky and everything goes according to plan, you will see questions you’ve never seen before – not from lecture, your USMLE World/Kaplan/USMLE Rx/other QBanks, or your NBME practice exams.  I have the utmost respect for the people who write for the USMLE Step 1, as they have done a fantastic job of creating questions that will test your ability to reason and apply your knowledge, and NOT your ability to memorize.  They’re not stupid, and they read the same resources we do, and will always make questions that we haven’t seen.

Remember, 50% of all of the pathology questions are designed to be “General Principle” questions (according to one USMLE Step 1 test-writer I spoke with).  So when you run into that question where you’re asking yourself, “WHAT??  I DIDN’T KNOW THAT I NEEDED TO KNOW THE CAUSES OF HEART DISEASE IN GAMBIAN RATS,” remember that you WEREN’T supposed to know the specific knowledge.  Just take a step back, and figure out what principle they want you to apply.

You are THIS close to feeling the immense joy of being done!

You are THIS close to feeling the immense joy of being done!

You’re Almost There!

If you’re wondering what you should be doing with 1-2 weeks left before your exam, congratulations!  You’re 1-2 weeks away from one of the best feelings in medical school – being done with your USMLE Step 1!  And if you are one of the many students who decides to push back their test date, don’t despair!  There is no better anxiety-reliever than walking into your test knowing that you did your absolute best to prepare for the exam – if it takes several weeks, or even months to reach that point, many people would tell you it’s worth it.

Either way, just to get to this point takes immense work, and you deserve a huge congratulations!

In summary:

  1. Assess where you relative to your goals with an NBME self-assessment
  2. Take 1-2 full-length (or 8-block) practice exams (may combine w/ Step #1 to for a score estimate)
  3. Schedule a Prometric site practice exam (Link)
  4. Do as many questions as possible
  5. Map our your test break/lunch strategy
  6. Shore up weak areas w/ active learning (Table of Contents)
  7. Embrace the unexpected

What do you think?  This list is by no means exhaustive – please share in the comments section other tips/advice you’ve heard from others/have used yourself!

Photos by: Bernard Goldbach, jessicahtam, Marina del Castell



With the FREE micro deck of more than 130+ Anki cards you will be practically BEGGING to get as many micro questions on your exam as possible.

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