The Think Twice Strategy Guide for the USMLE Step 1

By: Ross and Joe England

Introduction

This method was originally developed by Ross England, a Temple University student in the class of 2012,
to maximize his performance on the USMLE Step 1. With this method he achieved a 3-digit score of 262.
An outline of his method was distributed to the class of 2013 and received a lot of positive feedback.
Being his twin, I opted to use the same study strategy, with minor changes, and achieved an even higher
score of 271. It is our belief that anyone who commits to this study schedule early in their 2nd year of
medical school will improve their potential Step 1 score considerably.

The schedule for our approach to the boards can be divided into 5 stages: before winter break, after
winter break, Doctors in Training/review book reading, First Aid repetition, and a pre-test taper.

A detailed description of each stage follows below. Additionally, there are notes on whether or not to
purchase a Doctors in Training review course and on how to make the best use of the USMLE World Q
Bank.

Recommended Materials

Robbins and Cotran Pathologic Basis of Disease

Rapid Review Pathology

Lippincotts Pharmacology

Clinical Microbiology Made Ridiculously Simple

BRS Physiology

Lippincotts Biochemistry (or) Rapid Review Biochemistry

High Yield Neuroanatomy

How the Immune System Works

Doctors In Training (DIT) review course

USMLE World Qbank

Stage 1: Before Winter Break

Before winter break it is important to study hard for your classes while familiarizing yourself with the
board review material that you will be using in the future. [Strategic Point You dont want to be
reading anything new during your 6 week board review period. If you follow the advice below, you
will have broad exposure to every review source necessary to completely crush Step 1.] The schedule
is modeled after the Temple University School of Medicine core block schedule, but can be easily
adapted to any other medical school schedule.

[Strategic Point Its a good idea to add up the number of pages of textbooks and review books that
you will need to complete before each exam and then divide this number of pages by the number of
days you have until the exam. This will tell you how many pages you need to read each night]

Block 6: Introduction to Pathology, Pharmacology, and Immunology

-read all class notes/power points 2-3 times

-read the first 7 chapters of Robbins and Cotran Pathologic Basis of Disease (if you are pressed
for time and want to exclude some of this reading, read at least chapters 1, 2, 6, and 7 )

-read the relevant chapters of First Aid on basic pathology, pharmacology, and immunology

-read chapters 1, 2, 3, 5, 6, 7, and 8 of Rapid Review Pathology (1, 2, and 8 are most important)

Block 7: Microbiology

-read the sections of Clinical Microbiology Made Ridiculously Simple (CMMRS) relevant to
Bacteria, Fungi, and antibiotics during summer break

-read ALL of CMMRS again, preferably reading relevant chapters before the lecture on that topic

-pay close attention during lectures and add any obscure material that you think the professor
might put on a test that is not already in CMMRS into the tables at the end of each chapter

-study these self-edited tables (mentioned above) 2-3 times before each exam

-read the Microbiology chapter of First Aid at least once

-(Optional) Buy Microcards and add all info you want to remember about each organism that
isnt already on the cards

-(Optional) For a stellar score on the NBME shelf exam at the end of the block, read How the
Immune System Works chapters 1-8 (this is a very light read that will bring your intuitive understanding
of the immune system to a new level)

Block 8: Cardiovascular and Respiratory Disease

-read all class notes/power points 2-3 times

-read chapters 11, 12, and 13 of Pathologic Basis of Disease

 -read chapters 9, 10, and 16 of Rapid Review Pathology

-read the relevant chapters of First Aid

-read the relevant chapters of Lippincotts Pharmacology

Block 9: Endocrine, Renal/Urinary Tract, and Reproductive Disease

-read all class notes/power points 2-3 times

-read chapters 19-24 of Pathologic Basis of Disease (Ill admit, this is a ton of reading. Neither
Ross nor I was able to finish all of this, and if you want to cut corners too, focus on Chapter 20 only)

-read chapters 19-22 of Rapid Review Pathology (dont cut any corners here)

-read the Endocrine, Renal, and Reproductive chapters of First Aid

-dont worry about extra pharmacology reading for this block, the endocrine drugs/renal drugs
are covered well in First Aid

***Take it easy over winter break. I mean it. Dont study anything. Because you are in for a crazy 4
months when it is over***

Stage 2: After Winter Break

This is the time where you need to begin preparation for Step 1 in addition to your class studying. The
whole goal of this stage is anxiety management. We all had a block or two in the 1.5 years of medical
school that gave us trouble. Use this time to brush up on those subjects. For Ross, it was the first 7
chapters of Robbins and Cotran that he never got around to during Block 6. For me, it was High Yield
Neuroanatomy and about 1/3 of Lippincotts Biochemistry (plus the relevant First Aid chapters on those
subjects). I also subscribed to Kaplan Qbank for a month before the 6 week prep period began just to
boost my confidence in my question taking ability and to do class specific questions (more on this later).
[Strategic Point Use this time to brush up on a weak point or two ONLY! This will allow you the most
time to prepare for class and will lower your anxiety for what you will need to accomplish during the 6
week prep period. Trying to study for the entire Step 1 on top of classes is a recipe for unbearable
stress. ]

Block 10: Psychiatry, Neurological Disease, Musculoskeletal Disease, and Autoimmune Disease

-read class notes/powerpoints 2-3 times each

-read the psychiatry, neurology, and musculoskeletal chapters of First Aid

-read chapters 3, 23, 24, and 25 of Rapid Review Pathology

-read relevant sections of Lippincotts Pharmacology (especially psychiatry drugs)

Block 11: Gastrointestinal and Hematological/Oncologic Disease

-read class notes/power points 2-3 times each

-read the GI and Heme/Onc chapters of First Aid

-read chapters 11-15, 17, and 18 of Rapid Review Pathology

-read chapters 13 and 14 of Pathologic Basis of Disease

[Strategy Point Between the beginning of Stage 3 and the end of Stage 4 you should complete the
entire USMLE World Q Bank and go through all of the questions you got wrong again. You will need to
average 50-100 questions a day to achieve this goal. See the section How to Best Use the Q Bank
below for specific advice on how to maximize the time you spend doing questions.]

Stage 3: Doctors In Training (DIT)/Slow First Aid Review/Review Book Reading

DIT runs for 15 days. Ross and I both recommend that you do either DIT or spend an equivalent 15 days
carefully going through First Aid and looking up everything you dont understand. We also recommend
that, if you do DIT, you do all 15 days in a row and start the day your prep period begins. This will ensure
that you have all the high yield info in your First Aid before you start studying it in earnest. In the
evening after each DIT lesson or First Aid session, aim to read 80-100 pages of board review books.

[Strategic Point spending the first 12-15 days methodically reviewing First Aid, either on your own or
with the coaching of DIT staff, is invaluable]

Deciding on which board review books and how much of each will be highly personalized. In the table
below, Ross and I offer what little guidance we can. Using a variety of factors including your medical
school grades, how much you had to struggle to achieve those grades, your history with standardized
tests, your grades on the NBME shelf exams, etc. you can come up with a realistic goal score for
yourself. Table 1 shows a recommended amount of reading to complete during the first 15 days of the
study period (give or take 3 days, Ross and I both took 3 additional days to just finish reading) for four
different goal score categories.

Another thing to consider in choosing your amount of outside reading (by outside, I mean in addition to
First Aid) is your personal processing speed for reading. For example, even if you are capable, by all
other predictive measures listed above, of a score in the 225-240 range, but you know you are a slow
reader, you might want to do the recommended reading for the 210-225 range and spend the extra time
really focusing on First Aid.
 186-210 210-225 225-240 260-280
Rapid Review Pathology* 100% 100% 100% 100%
BRS Physiology 100% 100% 100% 100%
Lippincott's Pharmacology** 20% 40% 50% 60%
Clinical Micro Made Ridiculously Simple 80%
Rapid Review Biochemistry*** 100%
Lippincott's Biochemistry*** 70% 100%
High Yield Neuroanatomy**** 100% 100%
How the Immune System Works (Ch. 1-7) 100%
Table 1. Recommended Supplemental Reading for Different Goal Scores.(*For Rapid Review Pathology, take all blue margin
notes that are not already in First Aid and add them in. ** For Lippincotts Pharmacology focus on neurologic drugs
(psychiatric medications, seizure drugs, anesthetics), diabetes medications, and anti-arrhythmics. ***For biochemistry, focus
on metabolic pathways and experimental methods.**** On our resources webpage there are some valuable neuroanatomy
addendums prepared to go in your First Aid.)

[Strategic Point You can reduce the amount of reading you need to accomplish during Stage 3 by
using these resources to bulk up on your weaknesses in Stage 2. For example, I read all of High Yield
Neuroanatomy and much of Lippincotts Biochemistry before the 6 week prep period began]

Stage 4: First Aid Repetition

During this stage you will read between 80 and 120 pages of First Aid every day. When you come upon a
detail you did not know, write it down on a lined sheet of paper. Review the papers at the end of the
day, highlight things you STILL did not know, and then go over the highlighted items once more. Ross
and I both went through First Aid three times in addition to the first 15 day run-through. During each
round of First Aid you should see your Did Not Know (DNK) sheets decrease in number.

[Strategic Point: Each round of First Aid reading in Stage 4 should take between 3 and 6 days
depending on your reading speed and information processing ability. On days where you find the
material easier, try to get more pages done, thus leaving extra time to manage your trouble areas]

In addition to this, every other morning you should devote 30-60 minutes to going through the high
yield, hard-to-remember stuff. We recommend making a Drawing List of everything you want to
memorize (ex. glycogen storage diseases, seizure drugs, gram negative bacteria classification etc.). On
our website you will find some valuable resources for this purpose. One, in particular, is a list of every
set of hard to remember facts that comes with good mnemonic strategy in First Aid, for example SIG E
CAPS for the symptoms of depression. I recommend printing it, laminating it, and using dry erase
markers to practice. I cant make you an answer sheet because the mnemonics are copyrighted by First
Aid, but you can go through and easily find the answers yourself to make your own answer sheet.

[Strategic Point: These mnemonics are pre-prepared and they should be reflexive by test day. Dont
let studying difficult and obscure facts distract you from the completely easy, high yield concepts]
 Stage 5: Taper

Like preparing for any big athletic event, the taper is vital. Ross and I both took it easy the last 3 days
before the boards, doing maybe 75% intensity at 3 days out, 50% intensity at 2 days out, and 25% 1 day
out. The day before, we recommend you just quickly breeze through your Drawing Sheets and most
recent Did Not Know sheets, then just relax.

DIT: To Spend the Money or Not?

Many people ask if DIT is really necessary or not. Its a toss-up, but Ross and I both err on the side of it
not being necessary. Going through First Aid on your own with a fine-toothed comb and looking up
everything you dont understand in reputable references should be just fine. That being said, there are
some advantages to doing DIT. (1) It is low energy, allowing you to think more about the material at
hand without burning out. (2) It is active learning, with plenty of quizzes and educational study breaks in
the middle of the lessons. (3) It is an opportunity to be somewhat social many people in your class will
be doing DIT, and participating in the camaraderie and inside jokes is not a bad reason to sign up (the
cabin fever of those last 4 weeks of the study block are bad enough without making it 6 weeks
completely cut off from social interaction).(4) They have an awesome slogan.

How to Best Use the Q Bank

Some people buy the USMLE World Q Bank much earlier than the beginning of the study period and use
it to practice during Blocks 10 and 11 (or even earlier). This is not necessarily a bad idea, but it leads to a
common temptation: doing block specific questions from the QBank to prepare for your class exams.
Ross and I both think this is a waste of the best use of your QBank. Heres why:

USMLE World is, hands down, the best of the question banks (I tried a few of them). It is not just a
learning tool--it is a predictive tool that allows you to track your progress during your study period.

So lets say youre studying for your Heme/Onc exam and you succumb to the temptation to do all the
Heme/Onc questions in UWorld. Whats the big deal? The big deal is two-sided. First, you will likely get
high scores on those practice tests because Heme/Onc is all youve been studying for the last few weeks.
Second, you wont have any Heme/Onc questions left during your study period and will therefore be
inadvertently avoiding Heme/Onc questions for your entire board prep period.

All in all, you will have managed to inflate your percentage score on your UWorld account (leading you
to believe you are more prepared than you really are) while also cultivating a weakness (making you less
prepared than you otherwise would have been).

My solution is to use another question bank (I used Kaplan) during Stage 2 to practice subject specific
questions and to build confidence in your ability to answer Step 1 style questions correctly. Then
purchase UWorld at the beginning of Stage 3.

[Strategic Point always use random, timed mode including all subject areas in your practice tests
during Stages 3 and 4. This increases the predictive value of your scores.]
[Strategic Point Make a journal and jot down little facts you did not know from UWorld questions
especially the ones you dont think are in First Aid]

[Strategic Point - Do not be discouraged if your UWorld scores start to drop off slightly near the very
end. Once you have exhausted all of the easy questions, like biostatistics and ethics, the tests become
a little harder than they were in the earlier portion of your study period]

Score Prediction

Some websites have score predictors based on UWorld performance and other factors. Ross and I both
found that these predictions were not very accurate. In both of our cases, the self-assessment exams
produced by UWorld gave the most accurate prediction of our scores. There are two of them, and they
can be purchased separately or with a Q Bank subscription. All four exams (two for me and two for Ross)
predicted our respective scores within 6 points or better. It is probably best to do these assessments 1-
2 weeks before your exam date, to get maximum predictive value for your score while still giving you a
good idea of which topics still need work.

A Word on Maintaining Your Sanity

Ross and I have been told that this study schedule is intense, but neither of us thought it was all that
bad. A few tips on what might make these 12-15 hour days more bearable:

1. Exercise: If you arent already on an exercise program, you should consider starting one a
few weeks before your study period at the very latest. Do whatever kind of exercise you
want, but Ross and I think that the short duration, high intensity variety is optimal for board
studying. Do a set of sprints instead of a half hour jog. Lift heavy and fast instead of high
repetitions. Save yourself a trip to the gym by doing body weight exercises at home such as
push ups, pull ups, squats, etc. Better yet, mix all this together into 5-10 minute circuits that
leave you on the ground gasping for breath. Then immediately go do some studying (some
scientific studies have demonstrated an increase in information retention after intense
exerciseanything helps right?)
2. Nutrition: Get your nutrition in order at least several months before the boards. I know you
didnt read this guide for nutrition advice, but doing some research on the benefits of
carbohydrate restriction might be a good starting point. We dont buy into too many health
supplements, but there seems to be a strong body of evidence in support of fish oil and
vitamin D3 (stock upbecause sunlight will likely be in short supply for at least 6 weeks).
3. Sex: Have it as much as possible with a willing partner. If you dont have a willing partner, I
imagine some self love could go a long way towards stress relief. Thats all Im going to say
on that topic.

On Getting Honors in Temple

Doing everything I mentioned above will not only assist you in reaching your maximum Step 1 potential,
it will also help you on your medical school exams. One last tip towards this end: For blocks 8-11, always,
always, always do the relevant questions from Robbins and Cotran Review of Pathology. Many of the
professors take their questions directly from this book. It is low hanging fruit.